This section confirms basic information used for identification and communication.

Please complete all required fields, including:

• Legal name
• Date of birth
• Address
• Phone number
• Email address

Make sure your contact information is accurate, as portal messages and scheduling instructions are sent through this system.

This section helps your provider understand your past and current health concerns.

Please include:

• Current medical conditions
• Past diagnoses
• Surgeries or hospitalizations
• Significant illnesses or injuries

If you are unsure whether something is relevant, include it. It is better to provide more information than too little.

Please list all current medications and supplements, including:

• Prescription medications
• Over-the-counter medications
• Vitamins and supplements
• Hormones or injections

For each item, include the name, dose, and how often you take it if known. If you no longer take a medication, do not include it.

List any known allergies or adverse reactions, including:

• Medication allergies
• Food allergies
• Environmental allergies
• Reactions to medications or injections

If you have no known allergies, indicate this clearly if the option is available.

Family history helps assess inherited risk factors.

Please include known conditions in immediate family members, such as:

• Heart disease
• Diabetes
• Autoimmune conditions
• Cancer
• Thyroid disorders

If information is unknown, you may leave those fields blank or indicate “unknown.”

This section provides context for your health.

You may be asked about:

• Tobacco or nicotine use
• Alcohol use
• Exercise habits
• Sleep patterns
• Stress levels

Please answer honestly. This information is used to guide care, not for judgment.

If you are asked to upload documents, you may include:

• Recent lab results
• Imaging reports
• Prior medical records
• Relevant outside evaluations

Upload only documents that are relevant to your current care. If you do not have records available, you may proceed without uploading files.

These forms are required before scheduling and may include:

• Treatment consent
• Telemedicine acknowledgment
• Privacy and HIPAA notices
• Financial or membership acknowledgments

Please read each consent carefully before signing. If a required consent is not completed, your chart will remain incomplete.