IMPORTANT NOTE: EVERY SECTION THAT HAS A SMALL RED ASTERISK MUST HAVE SOMETHING FILLED IN EVEN IF YOU JUST TYPE N/A OR THE FORM WILL NOT SUBMIT SUCCESSFULLY. THERE IS ALSO A “CONTACT” PAGE AT TOP RIGHT THAT WORKS AS WELL.

AFTER SUBMITTING THE FORM PLEASE SEND ME AN EMAIL TO: davidscottmay@mac.com Subject: “Intake Form Submitted”

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First Name *

Last Name *

Patient Birthdate *

Patient Age *

Adult Adolescent Child

Main Phone *

Alternate Phone

Email Address *

Home Address *

Billing Address

(If different from home address)

Reason for Consultation *

Any Medication currently used *

Referred by

Referrer phone

Pharmacy Name *

Pharmacy Phone *

Pharmacy Address *

Regular Medical Doctor's Name *

Regular Medical Doctor's Phone Number *

Current Job *

Who Lives with Patient and Their Ages *

Other Important Information *