Please be forthcoming with your responses. All of your medical information is confidential.

• The time it takes to complete the form is dependent on your personal medical history. Someone with a more complicated medical history or list of medications will take longer. The average time to complete is 25-30 minutes.
• Upon receipt of your information, a staff member or nurse may call you for further clarification if necessary.

NOTE – You do not have to fill out a form again if you are returning to the same medical facility and have already completed this online form prior to a previous visit. A nurse or staff member will call you to discuss any changes in your medical history since your last visit.

Before you begin the online admissions form, please make sure that you have the following information available, as it may be needed to complete your form:

• Prescription medications – names and dosage of each one you take.
• Over-the-counter medication – names and dosage of each one you take regularly.
• Vitamin and herbal medications - names and dosage of any that you take.
• Allergies/Sensitivities you have, and the allergic reaction(s) they cause.
• Previous surgeries, and the year they were performed.
• Medical Insurance – insurance company, policy number, ID number, etc.