DFWMM  Health and Wellness Initiative Form

Disclaimer - Please use this form only for non-emergent matters. If this is a medical emergency, please dial 911 or go to the nearest ER. Healthcare providers from this initiative will not be able to prescribe medications as there is no physician-patient relationship established.

Please allow for up to 3 days for a response. You will receive the response as a phone call from members of this team.
Sign in to Google to save your progress. Learn more
Email *
DFWMM Member's name *
Name of Individual seeking advice
 *
Age  of Individual seeking advice
 *
Sex of Individual seeking advice
 *
Phone Number
 *
Email Address *
Describe your problem
 *
Is your issue related to 
 *
Prior medical issues and history
Current medications

Attestation: I agree that I am willingly providing the health-related information of the individual that is seeking assistance. I understand that this advice is not a substitute for actual physician visit or testing. I will not hold the provider that will help or DFWMM and its affiliates responsible for any consequences that arise. 

 *
Required
Sign: Full name
 *
Today's Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms