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, Yvonne Alvarez RN, or Jacquie Bartlett 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, Yvonne Alvarez RN, or Jacquie Bartlett RN.

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

Date

Medical Director - Dr. Frank DiMotta, Jeff McKinley DO