Ywellness Consent Form

Full Name

Phone *

Email *

City

State

Taking any medications, currently?

Yes

If yes, please list it here

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, Yvonne Alvarez RN, or Dr. Jill Sohayda MD 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 Dr. Taylor or Yvonne Alvarez RN.

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

Date *

Medical Directors: Dr. Frank DiMotta MD, Dr. Jill Sohayda MD