In order to undergo our medical consultation, we first ask you to complete the medical form below. This will be reviewed by our providers before we contact you to arrange your appointment. We understand the importance of protecting your personal information and these forms will be treated with total confidentiality.If you have any questions, please call our office at (813) 750-7470.
  • Drugs Currently Being Used

    • Add More Drugs
    • Most Recent Attempt to Withdraw

    • Past Medical History

      Medication currently being used (other than drugs mentioned above)
    • Medication 1
    • Add More Medication
    • Medication 2
    • Medication 3
    • Emergency Contact

    • Should be Empty: