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Please complete the form below to register with our service.
You are under no obligation.
Please review our Terms
and
privacy statement
Health & Medical History Questionnaire
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Medical Information |
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Please explain your health condition or cause of
pain for which you are seeking help. |
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Please define symptoms or complaints. |
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Please explain if there is a specific reason for
your condition or pain. |
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When (approximately) was the onset of your condition
or pain? |
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Are you currently under the care of a health
professional for your situation? If yes, please
describe. |
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Are you being treated for any health condition other
than that stated above? If yes, describe. |
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Surgeries and Treatments (Not Medications) |
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Have you had any surgeries, treatments, or special
procedures for your condition or pain? If yes,
please describe and state approximate date of last
contact. |
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What other surgeries, treatments, or special
procedures have you undergone in the past? Please
describe and state approximate date(s). |
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Are you currently undergoing treatments or
procedures from health professionals? |
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Have you ever received treatment for any drug
addiction? (Please indicate street or prescription
and approximate date.) |
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Have you even been denied insurance coverage for any
medical reason? Please describe. |
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Have you ever visited a medical professional for any
psychological problems such as depression, anxiety,
panic attacks, obsessive compulsive behavior, or the
like? If yes, please describe include dates. |
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Medications |
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What medications, prescriptions, or over-the-counter
are you currently taking? |
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Are you allergic to any medications? |
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What medications have you found most effective in
the past for your condition or pain? |
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Have you taken any medications that gave you a
negative reaction? |
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Do you take any "street" drugs? If yes, which ones
and how often? |
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I
hereby state that:
I have been informed of the risk of addiction from various
medications.
The medications are exclusively for my own use and are not being
obtained from any other source.
Should the medications ever be obtained by another source I will
promptly notify
Absolute Medical Solutions, Inc.
in writing.
The medications help me to lead a normal and productive life.
I do not have any kidney or liver disease or damage.
I authorize the transmission via electronic means of any
information obtained from me or on my behalf to facilitate or
complete the consultation. The billing and the prescription
preparation and the sending of prescription to the pharmacy.
Affirmation and Acceptance
All
statements above including the registration and in the health
status and medical history questionnaire are true and correct to
the best of my knowledge and recollection, with no material
omissions.
By checking the
box below, I also state that I have reviewed both the Terms
and Conditions and the statement regarding Privacy
and agree to and accept them both.
Upon completion of the above registration and
questionnaire, you must do the following to schedule your
consultation:
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Fax your
medical records (dated within the last twelve months) and
documentation to us at
561-526-1025.
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Include
in your fax a copy of your Driver's License or other
government issued photo identification, which shows your
date of birth.
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Select a
payment method from among the three alternatives provided.
Charges for
medications are in addition to the above fees
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