Thank you for choosing our office! In order to serve you properly, we need the following information. All information is confidential, and this form is encrypted and secure according to all HIPAA regulations.
Please list current medications, over the counter medications (this includes eye drops, vitamins) you are presently taking.
You are not obligated to sign any authorization below. You may revoke your authorization at any time. If you wish to do so, you must contact our office first.
Please list the family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis
Your information will be encrypted.