Toggle menu
844-536-3876
[email protected]
COVID-19
COVID-19 Testing
COVID-19 Treatment
COVID-19 Vaccinations
Commercial COVID-19 Services
Services
General Medicine
House Calls
Telemedicine
Prescription Services
Mobile Imaging
Physicals
Medical Weight Management Program
Lab Testing
Vaccinations
Cosmetic Services
Infusions & Injections
Vitamin Infusions
MAB Treatment
Remdesivir Treatment
NAD Therapy
Cosmetic Services
COVID-19
COVID-19 Testing
COVID-19 Treatment
COVID-19 Vaccinations
Commercial Services
COVID-19
Vitamin Infusions
Physicals
Prescription Services
Concierge Medicine
Return-To-Work Authorizations
Pediatric Services
Well Care
Sick Care
COVID-19
Bilirubin Testing
Travel Medicine Kit
Appointment
Log In
Medical History
Patient’s information
Name
*
Name
First
First
Middle
Middle
Last
Last
Date of Birth
*
Gender
*
Male
Female
N/A
Phone Number
*
Email Address
*
Address
*
Apt or Suite
*
City
*
State
*
Zip
*
Were you referred by someone? If so, who?
What service(s) are you interested in?
*
Medical Weight Loss Program
TRT or HGH
IV Drip or Injection
Biohacking Services
Mobile Imaging
COVID-19 Testing or Treatment
Physical
Lab Test
Other
Other
Emergency Contact
Emergency Contact Name
*
Emergency Contact Name
First
First
Last
Last
Relationship to Patient
*
Mother
Father
Guardian
Sister/Brother
Partner
Emergency Contact Number
*
Medical History
Check the symptoms that you’ re currently experiencing:
Allergy
Cardiovascular
Chest Pain
Diabetes
Ear / Nose / Throat
Eye
Fever
Gastrointestinal
Genitourinary
Hematological
Lymphatic
Musculoskeletal
Neurological
Psychiatric
Respiratory
Weight Gain
Weight Loss
Other
Other
Are you currently taking any medications?
*
No
Yes
Yes
Do you have any known medical allergies?
*
No
Yes
Yes
Are you currently under medical treatment?
*
No
Yes
Yes
Have you been admitted to hospital or had surgery within the last 2 years?
*
No
Yes
Do you use any kind of tobacco or have you ever used them?
*
No
Yes
Yes
Do you use any kind of illegal drugs or have you ever used them?
*
No
Yes
Yes
Do you use any kind of history of Pancreatic Disease or Pancreatitis?
*
No
Yes
Yes
Do you use any kind of history of Thyroid Disease?
*
No
Yes
Yes
Do you use any kind of history of Multiple Endocrine Neoplasia?
*
No
Yes
Yes
Do you use any kind of history of Type 1 Diabetes?
*
No
Yes
Yes
Do you have any other diseases or conditions? If so, please list them.
*
Height
*
Current Weight
*
Desired Weight
*
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Insurance
Will you be using insurance
*
Yes
No
Photo of Front of Insurance Card
*
Drop a file here or click to upload
Choose File
Maximum upload size: 104.86MB
Photo of Back of Insurance Card
*
Drop a file here or click to upload
Choose File
Maximum upload size: 104.86MB
If you are human, leave this field blank.
Submit
Start Over
has been added to the cart.
View Cart