INTIMATE HEALTH SOLUTIONS PATIENT FORM

General Patient Information

This form is designed and created only for medical purposes of the clinic. The Intimate Health Solutions aligned with the Data Privacy Act of 2012 (RA 10173). Rest assured that all the data will be used with confidentiality.
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We are open Monday to Sunday from 10am to 6pm. STRICTLY BY APPOINTMENT. WE ARE NOT ACCEPTING WALK IN PATIENT FOR PRIVACY
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Age*
Contact Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Reason for Consultation:*
Main Reason for Consultation:
Area of Concern:
Area of concern:*
Actual Photo of Concern: (Optional)

Cancelof
Date of visit:*

MonthDayYear
Date
Preferred Branch*
Time of visit:*

Hour Minutes

AM/PM Option
Maintenance Meds (if any):*
Allergies:*
Oral meds:*
Anesthesia:*
Where have you seen or heard about us:
Should be Empty:

General Patient Information