Below, you will find the most important part of your new patient appointment reservation: the Medical Health History.
You must complete this form within 2 business days of receiving it.
Please read this note to help you complete the 15 minute Medical Health History.
The below is critical to the successful completion and SUBMISSION of the Health History Form. Please read below before you proceed with the form.
Click Here => Medical Health History Link <= Click Here
1)This Medical Health History is an 11 page form with multiple sections and a total of 11 pages long, and you will need to go through all 11 pages to complete the forms.
Once you click the link, the first screen, shown below, will ask for your info. Please fill out your first and last name and email. Please ignore the cell phone box.
2) Many of the fields in the form are MANDATORY, and thus marked with a RED ASTERISK: *
You will not be able to complete/submit the form without answering ALL of the mandatory fields.
3) The navigation bar is located on top of the page in a black bar with green numbers. You will only have the ability to use < or > to move backward or forward between pages, in addition to the partially exposed numbers <1 2 3…11> (which don’t show up in full order). This will be your only navigation to move between pages.
See screenshot of red asterix mark, of navigation bar up top, and submit button all the way on the right top hand corner.
4) On page 11, the last page, when you sign your signature and put in the patient name and responsible party name, go to the UPPER RIGHT HAND CORNER to click the button SUBMIT. Below is a sample of the last page and signature field on the bottom LEFT (notice red asterix *). Press submit on TOP RIGHT corner of page as in the screen shot in Step 3).
5) The form has mandatory fields (marked with a RED ASTERISK: *), which require a checkmark, a date, or additional text details. You will not be able to complete the forms if you have missed any mandatory fields.
IF you have missed any mandatory fields (which almost everyone does) the form will give you a pop-up notice
=> “You still have X of the 80 required fields (marked with *) to fill in!”
Once you click okay, it will automatically take you the page of the missed mandatory field. Fill out the field with the red asterisk (*) and press submit again, and you will get another message
=> “You still have X-1 of the 80 required fields (marked with *) to fill in!”
Click okay again, it will again automatically take you the to the next page of the next missed mandatory field. Fill out the field with the red asterisk (*) and press submit again
=> Continue this process until ALL fields have been filled out.
=> Click SUBMIT again.
6) Unless you are located on the actual LAST page of the medical health history (page 11 of 11), you will get a pop up message when you press SUBMIT, that will say:
“YOU HAVE ONLY REVIEWED X of 11 PAGES, DO YOU STILL WANT TO SUBMIT?“.
Please ignore this message, press SUBMIT and your form will submit.
If you are on the 11th page when you press submit, you will get a messaging asking you
“Are are sure you want to submit and cannot change any info?”
Press OKAY and your form will be submitted successfully.
7) The doctor will review the form with the patient and sign in office – the patient will not be able to edit form.
8) For questions or difficulties, please call 860-677-2242.