If the form fails to submit, there is most likely an errant entry in the form that needs to be corrected. Please review for any highlighted mistakes and resubmit.
When the form is received in our office, the nurses will review your medical history and contact you if clarification or additional information is required. Otherwise, you will be contacted by one of our receptionists who schedule all consultation appointments. We do charge a consultation fee of $105.00 tax inclusive.
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Please provide first and last name, address and phone number:
Please list ALL Surgery History (Procedure AND Year AND Location)*:
Please list any medication allergies (rash, face, neck swelling, itching)*:
Please list any food or medication sensitivities (upset stomach, nausea)*:
Please list any medications, including pills, inhalers and patches or herbal prescriptions you are currently taking (prescription or over the counter) and their dosage (including birth control)*:
Please list any herbals, vitamins, natural supplements or additives that you are currently taking*:
Is there anything else I should know about your medical/obstetrical/surgical or psychiatric history?