Patient Information – Advanced Mens Performance

Patient Information Form

Name
First Last
Date of birth*
Date Format: MM slash DD slash YYYY
Age*
Please enter a number from 0 to 100.
SS#*
Address*
Street Address City State ZIP Code
Home Phone
Cell
E-mail address*
Occupation*
Name of Employer*
Name of Spouse/Legal Guardian (circle one)
Marital Status*
Emergency Contact*
Phone
Who is your primary care provider?*
Other Physicians you currently see
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:
Phone*
1. Laboratory reports*
- Select
- Yes
- No
2. Protected health information*
- Select
- Yes
- No
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.
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 Medicine
I agree Notice of privacy practices*
Notice of Privacy Practices
I agree Policies*
Policies