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Personal Health History
IMMUNIZATIONS AND DATES
HEALTH HABITS AND PERSONAL SAFETY
ALL QUESTIONS CONTAINED IN THIS SECTION ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.
FAMILY HEALTH HISTORY
Please complete the below section of you are a woman. If you are man, please click next until you get to the section titled "Men Only".
Please complete the below section of you are a man.
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
FINAL STEP Identify Verification Your doctor needs to verify your identify with a photo of your face and a photo of your government-issued ID. We need a photo of your face to confirm that the government-issued ID is yours.
HEALTH INSURANCE We accept ONLY the following insurances. Please select your insurance type to continue. If your insurance type is not listed below, please select $30 to make your consultation payment.
UPLOAD YOUR HEALTH INSURANCE CARD Your doctor needs to verify your health insurance. Please upload front and and back copy of your health insurance card now. You will be notified of your co-pay via email if applicable.
You have completed your application. Click submit to submit your application