Treatment Inquiry Form
Free Information Provided For Patients

How to use this Form:
n Use one Form per patient inquiry
n Type in the Form, on screen response, (complete applicable blanks). 
n
Press "TAB" to move between blank spaces. 
n
DO NOT CLICK ON "ENTER" while completing the form. If you do that, you will close the form and send incomplete Form!
n DO NOT press the  "BACK" button because all information will be deleted if you leave this web page.
n When form is completed, click on "Send  it In", below.



PATIENT INFORMATION:
First Name  M.I. .Family Name 
Sex  Male  Female
Date Of Birth  Age Months Years
Country  Code  Area Code  Day Phone Number  Night Phone Number 
Preferred Doctor/Therapist  Location: .City.  County. 
State  Country 
E.Mail Address 
 
u Medical Procedure / Condition or Illness you seek treatment:
Diagnosis 

Do You Smoke? Yes  No

Are you taking medications for a chronic or a continuing medical problem? 
The medications could be prescriptions drugs and or birth control medications, herbal supplements, vitamins... etc.
Yes  No
If yes, please type below the names of medications and last date of use:
.

 

.Date This Form was completed 


Race/Ethnicity (type X in applicable boxes):
.
.White/Caucasian
.Black/African-American
.Asian/Asian-American/Pacific Islander
.Hispanic/Latina
.Native American/Alaska Native
.Middle Eastern Descent
.Other:  Please Type Here 

© 2006 Consultants Institute


Welcome to
Consultants Institute
P.O. Box 748
Lake Forest, California 92609-0748, USA
 

Back To HOME PAGE