Medical and surgical services provided by physicians. No walk-ins
Patient Online Consult Form:
"Describe how you are feeling, e.g. I have a sore throat for x many days or my ear aches or it hurts when I urinate or I have a cut etc... at the end of this form, please attach pictures of the areas you would like us to assess."
*
Full Name:
*
First Name
Last Name
FULL ADDRESS
*
Street Address
City
State
Postal
CELL PHONE:
*
Please enter a valid phone number.
EMAIL:
*
example@example.com
DOB:
*
-
Month
-
Day
Year
Date Picker Icon
EMPLOYER:
HOW LONG EMPLOYED THERE:
FAMILY DOCTOR NAME:
PERSON TO CONTACT IN CASE OF AN EMERGENCY:
Name:
First Name
Last Name
Relationship:
Phone:
Please enter a valid phone number.
REFERRED BY:
Newspaper:(name)
Magazine:(name)
Friend/Family:(name)
Other:
Medical History
Date of Last Blood Work (i.e. during physical, surgery, traveling, etc.) :
*
-
Month
-
Day
Year
Date Picker Icon
Do you have Kaiser Insurance?
*
Yes
No
Do you have any allergies( penicillin, eggs, shellfish, metals, iodine, etc)?
*
Yes
No
If yes, please list:
Are you currently taking medications?
*
Yes
No
If yes, please list:
Do you have a bleeding disorder?
*
Yes
No
Do u have menstrual cycles that are heavy and last more than seven days?
*
Yes
No
Do you have a history of poor healing? (ie. Keloids, diabetes, etc)
*
Yes
No
Are you pregnant?
*
Yes
No
How many children do you have?
*
If you had children, did you have any through c-section?
*
Yes
No
Have you had a hysterectomy?
*
Yes
No
If Yes, Date?
-
Month
-
Day
Year
Date Picker Icon
Have you had your gall bladder removed?
*
Yes
No
Have you had your appendix removed?
*
Yes
No
Have you had weight loss surgery?
*
Yes
No
If yes,Which kind?
Have you ever had Bell’s Palsy?
*
Yes
No
Do you smoke?
*
Yes
No
If yes, how often and how much:
Have you ever had any problems with general anesthesia?
*
Yes
No
Have you ever had any problems with local anesthesia?
*
Yes
No
Have you had any previous surgery?
*
Yes
No
Describe type of surgery and date of year of surgery
Do you drink alcohol?
*
Yes
No
If yes, how often and how much:
Have you ever had a history of facial numbness or weakness?
*
Yes
No
Have you ever had a cold sore?
*
Yes
No
Have you ever had a herpes out-break?
*
Yes
No
If yes, how often?
Have you ever had an AIDS test?
*
Yes
No
What was the result?
Do you have high blood pressure?
*
Yes
No
Do you have varicose veins?
*
Yes
No
Have you recently had a weight loss or gain (over 10 lbs)?
*
Yes
No
Your current estimated weight (in lbs)
*
Your height ( in feet )
*
Have you ever had hepatitis or jaundice?
*
Yes
No
Do you have any eye problems?
*
Yes
No
If yes, please list:
Has any member of your family ever had a problem with local or general anesthesia?
*
Yes
No
Is there any medical condition that you have that I should know about?
*
Yes
No
If yes, please list:
Have you experienced a recent emotional crisis?
*
Yes
No
Explain: In the last two years, how many times have you been to emergency room?
*
You give us permission to talk to your doctor about your care at Vita Surgical Group.
*
Yes
No
Upload 360(take pictures from different angles) images of the areas you want to be consulted on.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload any recent labs within 12 months.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
ALL DISPUTES BETWEEN YOU AND US WILL BE SUBJECT TO INDIVIDUAL ARBITRATION ACCORDING TO THE FAA.
*
Yes
Submit
Should be Empty:
