Friday Fibroscan Series - Fatty Liver Disease
Please complete the registration form below for the Fatty Liver Disease Friday Fibroscan Series. PLEASE SUBMIT THE TIME FRAME YOU WISH TO MAKE YOUR APPOINTMENT AND THE FINAL FORM TO BE REGISTERED FOR THE EVENT.
Full Name
*
First Name
Last Name
Person Filling Out This Form (if not the Patient)
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Have you had a Fibroscan done in the last 6 months?
*
Yes
No
How did you hear about this event?
*
Community event
Provider referral
Social media
Other
Please select which date you wish to attend
*
*
Medication history
*
Rows
Currently
Past use (in past 3 months)
Never
Diabetes Medication (Metformin, Jardiance, Danuvia, Glimepiride, ect. )
High Blood Pressure Medication (Lisinopril, Losartan, Amlodipine, metoprole, Hydrochlorothiazide, ect.)
Cholesterol Medication (Atorvastatin, Ezetimibe, Rosuvastatin, ect.)
Thyroid Medication (Levothyroxine, Methimazole, Propylthiouracil, ect.)
GLP-1 (Ozempic, Wegovy, Mounjaro, ect.)
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