Control Panel | Control Panel

MEDICAL RECORDS RELEASE FORM

Have you been diagnosed with any medical condition in the past or currently undergoing treatment for any
medical condition? ( please list )

Any other Current medications?

Yes

List ALL current prescription medications and how often you take them

Current over-the-counter medications or supplements:

Allergies

Primary Care Physician

PCP phone number

Do you give permission for ongoing regular updates to be provided to your primary care Physician?

Yes

Are you currently pregnant or do you think you might be pregnant?

Yes

Are you planning to get pregnant in the near future?

Yes