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.
Authorization of Release of Information
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?
MEDICAL HISTORY
Past Surgical History (Enter approximate date for procedure that applies)
Family History (Please write who among your immediate family has the following)