C4L-Welcome

Please set up my Reconsultation

RECONSULTATION REQUEST

	Name

Last Name:

First Name:

Middle Initial:

Date of Birth:

eg: xx/xx/xx

E-mail:

required field Required,xxx@xxx.com

	Delivery Address

Street:

City:

State:

Zip Code:

	Telephone

Regular:

eg: xxx-xxx-xxxx

Cell:

eg: xxx-xxx-xxxx

Alternative:
(if any)

eg: xxx-xxx-xxxx

Health Status and Medical History Questionnaire

	General

For what health condition or cause of pain are you seeking help?

What are your symptoms or complaints?

Was there a specific cause to your condition or pain? If yes, what was the cause?

When (approximately) was the onset of your condition or pain?

Are you currently under the care of a health professional for your situation? If yes, please describe.

Are you being treated for any health condition other than that stated above? If yes, please describe.

	Surgeries and Treatments (Not Medications)

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

What other surgeries, treatments or special procedures have you undergone in the past? Please describe and state approximate date.

What treatments or procedures from health professionals are you undergoing now?

Have you ever received treatment for any drug addiction? (Please indicate street or prescription and approximate date.)

Have you even been denied insurance coverage for any medical reason? Please describe.

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 including dates.

	Medications

What medications, prescription or over-the-counter are you currently taking?

Medication	Amount	Frequency

What medications are you allergic to?

What medications for your condition or pain have you found most effective in the past?

What medications that you have taken have given you negative reactions?

Do you take any "street" drugs? If yes, which ones and how often?

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 also be obtained from another source I will promptly notify us 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.

Affirmed and Accepted
My checkmark here is equivalent to my signature.

Upon the completion of the above registration and questionnaire, to schedule your consultation you must now:

Submit your medical records and documentation to us via fax
Include in your fax a copy of your Driver's License or other government issued photo identification, which shows your date of birth.
Select a payment method from among the three alternatives provided

The most convenient time for my telephone medical consultation is:
In the morning at about	a.m.
In the afternoon at about	p.m.
In the evening until	p.m.

Message Board VIP Discount Code

PAYMENT AND DELIVERY INSTRUCTIONS

Payment Type:

COD (Add $14)

Name On Card

Credit Card Number

Expiration Date

Security Code

Billing Address

Street

City

State

Zip

Shipping Address

Street

City

State

Zip

DELIVERY OPTIONS

Federal Express: Standard Overnight $26