Street Address Line 2
State / Province
Postal / Zip Code
I am a new patient.
I have a few changes to my personal information.
I have recently updated my personal information this year.
Enter your weight in kilograms (kg), Example: 98.5.
Enter your height in centimeters (cm), Example: 182.88.
Enter your Age, Example: 26.
Enter your Birth Date, Example: dd/mm/yyyy.
Please list the most important symptoms, concerns or questions you have today.
Do you have a prescription to include with this form?
Yes, i have an image of my prescription.
Send us an image of your prescription
Take a picture of your prescription and upload it by pressing the Upload Prescription button.
Should be Empty:
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