Patient Forms

Please fill out both the Medical Hx Form and New Patient form before your first visit
(or at the request of our front office)
This will help us serve you faster during your visit.

New Patient Information

New Patient Information

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First
Last
Middle Initial
Physical Address *
Physical Address
City
State/Province
Zip/Postal
Country
Mailing Address
Mailing Address
Mailing Address
City
State/Province
Zip/Postal
Country
Medical Hx Form

Medical Hx Form

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Last

Section

Are you under a physician's care now? *
Are you under a physician's care now?
Have you ever had a serious head or neck injury? *
Have you ever had a serious head or neck injury?
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates? *
Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?
Do you use tobacco? Smoking or chewing? How much? *
Do you use tobacco? Smoking or chewing? How much?

Section

Have you ever been hospitalized or had a major operation? *
Have you ever been hospitalized or had a major operation?
Ar you taking any medication, pills, or drugs? *
Have you ever been hospitalized or had a major operation?
Are you on a special diet? *
Are you on a special diet?
Do you use controlled substances? *
Do you use controlled substances?
Women: Are you...
Are you allergic to any of the following?