Contact Us - Medical History Form - Encrypted - For questions or concerns please email Taylor@WozWellness.com

Patient Information

First name

Last name

Date of birth

Gender

Contact Information

Phone number

Email address

Address

City

State

Zip Code

Medical History

Is this your first visit with Dr. Woznica?

Yes No

When was your last treatment with Dr. Woznica and what did you have treated? (If applicable)

What areas are you interested in treating?

What is your primary health goal?

Examples: Go 24 hours without back pain. Play golf again. Play tennis without elbow pain.

Which location are you seeking treatment at?

Chicago West Palm Beach In-Home Concierge Care

If traveling to an office location, where are you traveling from?

We will always do our best to accommodate flight/travel schedules.s!

What medications are you taking (not supplements or vitamins) ?

List any allergies to medications, latex, or foods.

What surgeries have you had?

Additional Comments or Questions

Please leave any additional information you would like Dr. Dave to be aware of in this section.

Please upload any health records here. If you have any issues please contact Taylor@WozWellness.com

Add file

Please upload a file

How Did You Hear About Us?

Word of Mouth from a Friend

Online (Facebook, Instagram, etc.)

Google / Web Search

Event

Other

If referred by a friend, who can we thank for your referral?

Would you like to receive Dr. Woznica's e-newsletter? We will never share your email with third parties & you can opt out at any time.

Yes

I'd like to receive information about clinic dates & news

No, do not send me emails unless it pertains specifically to my health

By submitting this form you agree to Woz Wellness terms of service and patient policies found here: https://wozwellness.com/services/pricing-payment-policies/

Prolotherapy, PRP, and Stem Cell treatments are not covered by any insurance provider. Woz Wellness is an an out-of-network provider.

No-shows and cancellations made within 24 hours of your scheduled appointment will be charged a $50 fee to the credit card given on file at the time of booking.

Your information will be encrypted.