New Patient Form

Please correct the errors described below.

Disclosure of Health Information: I wish to allow disclosure of my heath information to the following family members, friends or individuals. I understand that I may change this list at any time by informing this office in writing of the change.

Add Family Member

PLEASE READ AND SIGN

The above information is correct to the best of my knowledge, and I consent to such diagnostic procedures and medical care as deemed necessary by the doctor for my treatment. I also consent to having photographs taken, which will be used for medical treatment at the discretion of the doctor.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Medical History

Medications (Provide a list of all medicines you take, or complete the patient medication form)

Social History:

Family History

Review of Systems (Check all that you are currently experiencing)

Women:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Medication List

Medications (List all medications you currently take. Include prescriptions, OTC, Vitamins and supplements)

Add Medication

Your information will be encrypted.

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