First Name
*
Last Name
*
Gender
Male
Female
Prefer not to say
Social Security Number
Birth Date
*
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Month
-
Day
Year
Date
Street Address
*
City, State, Zip Code
*
Best Phone Number
*
Email
example@example.com
Height / Weight
Employer Information
The average American spends 40% of their life at work. It's important to us to understand what you do and who you do it with.
Your Occupation
Employer
Emergency Contact
In case there's an emergency -- who should we contact for you?
Emergency Contact
*
Emergency Contact Phone number
*
Family Members
Tell us about your family.
Marital Status
Single
Married
Divorced
Widowed
Separated
Spouse's Name
Child's Name & Age
Child's Name & Age
Child's Name & Age
Primary Physician
If there's an opportunity to collaborate with your primary physician -- we will.
Physician's Name
Acknowledgements
By checking the box, you are agreeing to the following:
Acknowledgements
*
I have read and reviewed the Privacy Policy (https://vitalitydoctors.com/wp-content/uploads/2015/08/doc04704720150513092316.pdf) and understand it describes how my personal health information is released on my behalf for seeking reimbursement from any involved third parties.
I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails, or health information to me as an extension of my care in the office.
I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services I receive.
I may request a copy of the Financial Policy at any time.
To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.
How Did You Hear About Us?
If someone (or something) sent you here, we'd like to know so we can thank them.
Who can we thank for referring you?
How Can We Help You?
Tell us about the problems you are experiencing.
My problem is:
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