TurchCare Patient Information Form
Full Name
First Name
Last Name
What is your age?
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Email Address
example@example.com
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Signature
Appointment
Upload Your Photos for Medical Evaluation.
Browse Files
Drag and drop files here
Choose a file
Please upload clear photos of treatment area (front, top, and sides). These photos will help our medical team provide you with personalized assessment. (All photos are kept strictly confidential.)
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Who referred you to Turch Care?(Please include their full name or organization name, and phone number if available)
Name Surname
Organization Name
Referrer’s Phone Number (optional)
Please enter a valid phone number.
Continue
Continue
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