Primary Information
The following information is going to help us qualify you and give you the best treatment possible.
Full Name
*
First Name
Middle Name (optional)
Last Name
What is your phone number?
*
-
Area Code
Phone Number
Please enter your Email address.
Confirmation Email
It's crucial we have the correct email for your account.
What is your Date of Birth?
*
January
February
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1922
1921
1920
Year
Please select your Sex.
*
Male
Female
Please enter your SSN (Social Security Number).
Please enter your ethnicity.
*
Please enter your height (inches).
Please enter your weight (lbs).
What is your Address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact: Please provide a name and number.
What is the name of your employer?
Please enter your preferred pharmacy.
Please enter your insurance provider if you have one.
Date
*
-
Month
-
Day
Year
This field is locked by default.
Please accept the following agreements so we can proceed with your medical visit.
*
I agree to the
Privacy Policy
,
Terms and conditions
, and
Telehealth Consent
.
Do we have permission to text or call you?
*
Yes
No
Do we have permission to access your medical history from 3rd party sources?
*
Yes
No
Back
Next
Boro Medical and Lifestyle Visit
Please give us some more information so we can better assist you.
What is the reason for your visit today?
*
When did this incident occur?
*
How severe is your injury?
*
(1-10) Least to Highest
1 (No Pain)
2
3
4
5 (Moderate Pain)
6
7
8
9
10 (Severe pain)
Does any motion or movement cause pain?
*
Yes
No
Please describe this in further detail.
*
Does your injury radiate to any other part of your body?
*
Yes
No
Please describe this in further detail.
*
How did you hear about us?
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Next
Medical History
Please give us a brief overview of your medical history
Any known Medical Problems?
Any Past Surgeries?
Any Past Hospitalization?
Please enter any medications you are taking, one per row.
Any Family Medical History?
Please enter any known Allergies, one per row.
Do you use tobacco?
*
Yes
No
Previous user
Do you use alcohol?
*
Yes
No
Previous user
Do you use drugs?
*
Yes
No
Previous user
Immunizations
*
Up to date
Not up to date
Unknown
Submit
Should be Empty: