WELCOME: The doctor and staff welcome you and want you to provide you with the best possible care. We will conduct a thorough history and physical examination to decide if we can assist you. If we do not believe that your condition will respond to our care, we will refer you to the appropriate healthcare provider. If you are a candidate for care in this office, then a treatment plan will be recommended to fit your individual needs.

INSTRUCTIONS: Please complete the following information in its entirety. The information submitted on this form is strictly confidential. If you have difficulty understanding any portion of this form, please ask for assistance. If the question does not pertain to you, simply write in N/A for non-applicable.

PLEASE FILL OUT THIS FORM ENTIRELY. YOUR ANSWERS DO NOT SAVE UNTIL YOU CLICK SUBMIT AT THE END OF THE FORM. THIS FORM SHOULD TAKE APPROXIMATELY 10 MINUTES TO FILL OUT.