In order for us to obtain a complete medical history and treat the medical condition that you are seeking help with; we need this form filled out as completely as possible.

I authorize the following person/people to discuss any necessary appointments, treatments, medications, test results, or anything else related to my medical care and/or appointment scheduling. I authorize the following person/people to bring in my child in for treatment and to discuss any appointments, treatments, medications, test results or anything else related to their medical care and/or appointment scheduling.

Who would you like us to contact in the case of an emergency?