Medical Visit Patient Infomation Name(Required) First Last Date of birth(Required) MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Enter Email Confirm Email Who referred you?Name / Google / Facebook / Instagram / Other Chief ComplaintConcern / Reason for visit Please mark the parcipitating factors that pertain to you. Inactivity Overeating Sedentary Job Age Injury Childbirth Stress Depression Medication Hysterectomy Blood Pressure Cholesterol Diabetes Infection Allergy Asthma Other (specify below) Other / Additional Details / Date of Diagnosis Past Medical History? Asthma Cervical Cancer Despression Diabetes High Blood Pressure Infertility Menopause Obesity Thyroid Dysfunction Migraines None Other (specify below) Other / Additional Details / Date of Diagnosis Past Surgical History? Back Surgery Breast Augmentation C-Section Gall Bladder Gastric Stapling Hernia Hysterectomy Laparoscopy Liposuction None Other (specify below) Other / Additional Details / Date of Diagnosis Family History? Adopted Cancer Depression Diabetes Heart Disease High Blood Pressure Obesity Stroke None Other (specific below) Other / Additional Details Social History? Occasional Drinking Occasional Smoking Never Please provide additional details Are you currently taking any medication or supplements?(Required) Yes No Are you currently taking any medication or supplements? If yes, please list with dosage. Are you ALLERGIC to any medication or supplements? Yes No Medication & Reaction Legal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically. My signature below means I understand the following. All of the information I have provided is true and to the best of my knowledge. Patient Signature(Required)CAPTCHA
