Thank you for reaching out to Healing Hands of Nebraska. To make this process easier, we've included the actual form in this email - please feel free to fill it out directly here in your email. Alternatively, if you'd prefer, you can click on the "FILL OUT IN GOOGLE FORMS" at the top.
In order to schedule an appointment with Dr. Aguila, he requests that each patient complete this form.
If your symptoms are not pain-related, please give as much detail as you can regarding the type of symptoms you have, when, how often, how severe, and how it has been treated in the past.
Please also email us (firstname.lastname@example.org
) any supporting documentation (MRI / CT / X-ray reports, etc) that you think might be helpful.
Finally, please click "Review and Submit" at the end of this form to send the information back to us, and we will get in touch with you shortly.
The Healing Hands of Nebraska Team