New Telehealth Patient Paperwork

Thank you for scheduling a telehealth appointment with one of our specialty-trained doctors. Please fill out and submit the following new telehealth patient form below.

Medical Disorder: Please select any of the following you have had.
Surgical History: Please select any of the following you have had.
Family History: Please select any of the following that a family member below has had.
Father Medical History
Mother Medical History
Sibling Medical History
Review of Symptoms: Please select any of the following you have had.
Constitutional
Cardiovascular
Musculoskeletal
Eyes
Skin
Blood or Lympha
Ear Nose Mouth Throat
Neurological
Respiratory
Gastrointestinal
Genitourinary
Endocrine
Immunologic
Psychological
Social History: Please select answers for the following questions.
Do you use tobacco?
Do You Use Alcohol
Do You Use Caffeine?
Do You Use Illicit Drugs?
Hand Dominance?
(Females Only) Could you be pregnant?
Allergies: Do you have allergies to any of the following medications or substances? *
Other Allergies
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