Boro Medical & Lifestyle Patient Check-in

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? *

Month Day 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

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? *

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?

Primary Information