FLOURISH: New Patient Intake

Legal Name

First NameMiddle NameLast Name

Preferred Name

Best E-mail

Preferred Pronoun

Sex at Birth

Gender Identity

Sexual Orientation

Date of Birth

MonthDayYear

Height (inches)

Weight (pounds)

*We do not use weight as an indicator of health. Please decline to answer per your preference.

Phone Number:

Area CodePhone Number

Is it okay to leave a detailed message at this number?

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Is it okay to send marked mail to the address?

How did you hear about FLOURISH?

In case of emergency...

Emergency Contact:

First NameLast Name

Phone Number

Area CodePhone Number

Relationship

Allergies to medications:

Other allergies/sensitivities:

Please list any medications you are currently taking:

Include medication name, dosage, how often taken, reason for taking, and how long it's been taken. If more than one, separate with commas. If it's easier, you may bring all of your bottles to your appointment.

Please list any herbs/supplements you are currently taking:

Include supplement name, dosage, how often taking, reason for taking, and how long it's been taken. If more than one, separate with commas. If it's easier, you may bring all of your bottles to your appointment.

New Patient Intake

Medical History

Medical History

Medical History

Medical History