arcticmedicalcenter.com - Gainswave Intake

Gainswave® Intake
Patient Name:

First NameLast Name
DOB:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.
Email:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What area(s) of improvement are you interested in?
List any ED medications you are currently taking or have used in the past:
Did they work?
List any conditions/medical history you currently have or have had in the past:
List any known allergies:
When was the last time you saw a doctor for a physical exam?
List all medications and supplements you are currently taking:
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of the staff responsible for any errors or omission that I may have made in the completion of this form.
Signature:

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Date:

MonthDayYear
Date

Gainswave® Intake