Patient Information Form

  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 100.
  • Please 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:
  • If 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.