Health History Form

Please correct the errors described below.

DO YOU HAVE ANY PROBLEMS WITH THE FOLLOWING BODY FUNCTIONS OR CONDITIONS? (IF YES PLEASE EXPLAIN)

If yes, please list your personal or referring physician below. By listing the name(s) and signing below you give your permission for Dr. Stoller to communicate with them for purposes of your medical care.

PLEASE NOTIFY OUR STAFF IF YOUR BLOODWORK OR PATHOLOGY SPECIMENS REQUIRE A SPECIFIC LABORATORY FOR TESTING.

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.

Your information will be encrypted.

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