Integr8 Health COVID-19 Intake
Please complete this intake form if you are scheduled for a consultation for COVID-19 prevention or treatment. The information you submit in this HIPAA-secure form is protected health information and will be used only by this office unless you provide a written release. **Please do not use use your auto-fill function, it creates a problem for some users that prevents advancing and completing the form**
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Email *
First name *
Last name *
Date of Birth *
What is your gender *
Primary phone *
Secondary phone
Home address *
Emergency contact name, relationship, and phone number *
Medical History: please select any conditions that you have or have had in the past *
Required
Additional Health History: please include any current medical conditions, past serious illnesses, surgeries, or hospitalizations not listed above. *
Please list your current medications, supplements and herbs, including dosage and frequency. *
Allergies: *
Please provide the name and town of your primary care provider.
Current weight (lbs) *
Height *
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