Mark the corresponding box next to any of the following illnesses you have had:
Mark the corresponding box next to any of the following medications you are taking or have a reaction to:
Please list the name(s) of the medications and dosage:
I understand that if I cancel an appointment without giving at least twenty-four (24) hours notice I will be billed $50. I agree to pay this broken appointment fee within 30 days of the date of the broken appointment.
I certify that the above health history is accurate and I will notify you of any change in my physical condition.