New Patient Registration

Please fill in the form below

Full Name *

Email *

Sex

Male

Female

Other

Date of birth

Phone *

Address:

City

State

Country

Postal code

Emergency Contact name and Phone Number:

Physician Name and Phone:

How did you hear about us?

Medical History

Please describe the reaction you experienced:

Taking any medications, currently?

Yes

No

If yes, please list it here

Female Clients:

Are you pregnant or trying to become pregnant?

Yes

No

If pregnant what week of pregnancy are you in?

Are you breastfeeding?

Yes

No

Informed Consent

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform Dr. Taylor and Yvonne Alvarez RN of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. I agree to receive treatment from Dr. Taylor and or Yvonne Alvarez RN.

Please Type Your Full Name as Signature of agreement of Informed Consent and certification statement.

Date

Medical Director - Dr. Frank DiMotta, Jill Sohayda