Intake Form Intake Form Today's Date Patient Name Date Of Birth Phone Number Email Address Address Occupation Enrollment Status Employed Full Time Employe Part Time Unemployed SSN (Optional) Driver's License State Driver's License Number Are You Currently Taking Any Medications? Yes No Emergency Contact Name Emergency Contact's Phone Number Emergency Contact's Relationship To Patient? Erectile Dysfunction - When did it start? Have you tried any of the following?: Viagra Cialis Levitra None Of The Above All Of The Above If so, how did it work?: Did you experience any side effects?: How Frequently Do You Have Morning Erections?: Weekly Monthly Almost Never Medical Conditions: Please List All Medical Problems: Please List Current Medications / Supplements : Please Describe Surgical History: Privacy Notice (HIPPA) I Agree I Disagree Informed Patient Consent: By Typing Your Name Below You Agree To The Informed Patient Consent Send © All rights reserved Privacy Policy Sempra Medical Group Share this:TwitterFacebookLike this:Like Loading...
