We care deeply about protecting your medical information and personal data. Before sending any forms electronically, please note that email communication carries some privacy risks.
To better protect your privacy, we recommend using our printable version of the form which you can find in our website. You can print it, complete it, and bring it with you to the clinic.
I acknowledge the risks associated with email communication and consent to send forms electronically.
Does any of your close relatives have any of the following conditions (parents, grandparents, siblings, aunts/uncles)?
Please check all that apply and add details if possible. Example: dates/hospital/surgeon
Medical History: Please check the boxes
