Current Health Issues
Please answer the following questions form to list and describe any current health issues.
Be as specific as you wish.
Make sure to list refills of Herbal or Health products.
We will print this form with the Reverse Side as your SUPERBILL receipt. Please ask for a diagnosis code if you plan on filing with your Insurance Company
Please ensure you complete all the fields marked with an asterisk *.
All information is held in strictest confidence. No information is disclosed or shared without your written consent. You may choose to skip answering any question you do not wish to disclose other than the fields marked with an asterisk *.