Medical Information Form | YVSC

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MEDICAL INFORMATION

To facilitate your visit, please provide the following information:

First Name

Last Name

List any surgeries you have had

List medical conditions for which you are currently under treatment (high blood pressure, diabetes, heart disease, asthma, etc.)

List any allergies you have to medications and the reaction (for example, penicillin—rash)

Please indicate if you use tobacco, alcohol, or recreational drugs

Alcohol

Tobacco

Recreational Drugs

None

Please indicate your understanding of why you are having this procedure

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

You're almost done. Just fill out the List of Medication Form. and you'll be finished.

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