Patient Check-in Boro Medical & Lifestyle

Primary Information

The following information is going to help us qualify you and give you the best treatment possible.
Full Name*

First NameMiddle Name (optional)Last Name
What is your phone number? *

Area CodePhone Number
Please enter your Email address.

Confirmation EmailIt's crucial we have the correct email for your account.
What is your Date of Birth? *

MonthDayYear
Please select your Sex.*

MaleFemale
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

CityState / 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*

MonthDayYear
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?*

YesNo
Do we have permission to access your medical history from 3rd party sources?*

YesNo

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?*
Does any motion or movement cause pain?*

YesNo
Please describe this in further detail. *
Does your injury radiate to any other part of your body?*

YesNo
Please describe this in further detail. *
How did you hear about us?

Primary Information