Primary Problems
If it applies, please draw in the pictures below where this has bothered you or your child
Health Providers
Other medical conditions/diagnoses
Please list all medications, supplements, herbs, remedies and vitamins that taken:
Please list all allergies and intolerances
BIRTH HISTORY
Father
Mother
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.