Medical History Form
To effectively serve you and optimize your virtual consultation, it is essential to know all we can about your medical history. Your information is strictly confidential, and will never be shared with anyone unless you give us written permission.
There are two ways you can complete your Medical History Form and submit it to us:
- Complete the form online, save the PDF, and email it as an attachment to firstname.lastname@example.org.
- If you are unable to fill out the form online, you can print out the Medical History Form instead and take a photo of it and email it to us at email@example.com.
We look forward to getting to know you and getting started with your virtual consultation.