General Information

Medical Status

Medical Conditions

Current Symptoms  - Please note the severity of the symptoms you are experiencing (0 - none, 5- severe)

Medical History

(Please check all that apply to you or a family member)

Indicate 'self' or how realated to you

If 'self', indicate date of dignosis

Insurance Coverage

*Please note this information will be used to determine coverage only. No medications will be billed to your insurance without your consent.

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