Patient Forms

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Note: All customer and patient records are guaranteed to be private as protected by Federal HIPPA laws, and these records can only be released to outside parties with the signed permission of the patient.

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Chronic Illness *

Do you have a history of chronic illness, such as heart, lung, or other inflammatory issues? If you answer "yes," please elaborate below, thank you.

Yes

No

Drug Allergies *

Do you have any known drug allergies? If you answer "yes," please elaborate below, thank you.

Yes

No

Medication *

Are you currently on any medication? If you answer "yes," please elaborate below, thank you.

Yes

No

Sulfa / Chemicals *

Do you have any sulfa and or chemical sensitivities? If you answer "yes," please elaborate below, thank you.

Yes

No

Covid Status

Have you or anyone in your household had any of the following symptoms in the last 21 days? Please check all that apply. If you answer "yes" to any of the prompts, please elaborate below, thank you.

Sore throat

Cough

Chills

Body aches for unknown reasons

SOB for unknown reasons

Loss of smell

Loss of taste

Fever at or above 100 degrees Fahrenheit

Exposure

Have you been in contact with and or exposed to anyone who has tested positive for COVID-19? If you answer "yes," please elaborate below, thank you.

Yes

No

Date Exposed

If you have been exposed, please indicate the date below, thank you.

MM

DD

YYYY

Symptoms

Are you experiencing any symptoms? If you answer "yes," please elaborate below, describing the severity of said symptoms, thank you.

Yes

No

Testing

Have you been formally tested for COVID-19?

Yes

No

COVID-19 Medication

If you have COVID-19 symptoms, have you taken any medication to alleviate them? If you answer "yes," please elaborate below, thank you.

Yes

No

Vaccines

Have you received one or more does of a COVID-19 vaccine. Please check all that apply. If you answer "yes," please elaborate below, thank you.

Pfizer

Moderna

Johnson & Johnson

A combination of companies

A different company and or pill, etc.

No, I have not received a vaccine at this time.