MEDICAL HISTORY FORM

Please provide the information requested below, to the best of your ability. Once you've completed the form, a member of patient outreach team will get back to you as soon as possible.

If you have any questions or comments please contact Elizabeth Garcia, patient coordinator, at elizabeth@giostarchicago.com. You can also reach us at 844 446 7827

MEDICAL HISTORY FORM (2 of 5)

Please use date picker or enter in format mm/dd/yyyy; e.g., 11/05/1963

Street Address

Street Address Line 2 (e.g., Apt., Suite)

City State / Province

Postal / Zip Code

Elizabeth Shelly Debra Bianca No One

Weekdays during the morning (09:30 AM-12:00 PM CST) Weekdays during the afternoon (1:00 PM-3:30 PM CST) Saturdays (10 AM-2 PM CST) Flexible (all options work for you)

Type "None" if you have no allergies

MEDICAL HISTORY FORM (3 of 5)

I am pregnant I am trying to become pregnant I am breast feeding I am using contraception None of the above

MEDICAL HISTORY FORM (4 of 5)

I am pregnant I am trying to become pregnant I am breast feeding I am using contraception None of the above

MEDICAL HISTORY FORM (5 of 5)

I understand that a deposit is required to lock in any promotional pricing. I understand that if, for any reason, I must cancel my appointment on the scheduled appointment date, I am subject to forfeiting half of the total procedure cost, which will include the security deposit, for the procedure. I understand that I must give 2 weeks notice if I need to cancel my scheduled appointment. Failure to do so will subject in losing the amount paid.

Type "None" if not applicable.

Medical History Form