New Patient Form

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Zip/ Postal Code
Pharmacy Phone Number
Past Medical History
If you don’t have any allergies, no response is necessary
Family Medical History
Insert total # of pregnancies, any miscarriages/ abortions, C-section deliveries, & vaginal deliveries. Skip if no prior pregnancy.
Currently using any Tobacco products?
Any consumption of tea, coffee, or sodas?
Are you sexually active?
Do you exercise often?
Do you consume alcohol?
Review of Symptoms