Patient Information Form Name First Last Date of birth* Age*Please enter a number from 0 to 100.SS#*Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home PhoneCellE-mail address* Occupation*Name of Employer*Name of Spouse/Legal Guardian (circle one)Marital Status*Please SelectSingleMarriedDivorcedSeparatedw/PartnerWidow(er)Emergency Contact*PhoneWho is your primary care provider?*Other Physicians you currently seePlease choose Yes or No to the following and initial: I authorize employees or agents of Advanced Men’s Performance to leave a detailed message for me on a voice message device associated with the below phone number regarding my:Phone*1. Laboratory reports*SelectYesNo2. Protected health information*SelectYesNoIf you answered NO to either of the above, the physicians and/or staff members at XaniVis Optimal Health will, as necessary, leave a message indicating your need to call us to retrieve any of your health-related information.Whom can we thank for referring you?Please list any drug allergies and your reaction: I agree Informed Consent and Request for Naturopathic Medicine* Informed Consent and Request for Naturopathic MedicineI agree Notice of privacy practices* Notice of Privacy PracticesI agree Policies* Policies This iframe contains the logic required to handle Ajax powered Gravity Forms.