Last Name:
First Name:
Age:
DOB:
Phone:
Email:
Address:
Days and times available for appt:
Notify openings from cancellations?
Emergency Contact:
Emergency Contact Phone Number:
Health Concerns:
Date of Onset:
Allergies:
Breastfeeding?
List all Medications:
Vaccines and dates:
Antibiotics and dates:
Supplement #1:
Brand:
Dose:
Date Started:
Notice if help?
Supplement #2:
Brand:
Dose:
Date Started:
Notice if help?
Repeat for other supplements:

Place an ‘X’ where applicable:
Supplements:
– Interested in purchasing at visit:
– Prefer link to order later:
– Not interested:
Testing:
– Food/yeast ($183.35):
– Hormones-blood ($124.20):
– Hormones-DUTCH($300):
– Thyroid ($81.77):
– Nutrients ($varies):
– Mold testing ($95.22):

Occupation:
How did you hear about Dr. Lee?
Will you be submitting receipts to insurance?
Need garage door open to avoid stairs?
Clinic Policy requires payment at time of services. Please cancel 24 hours in advance. If you do not cancel 24 hours in advance for return visits, you will be charged $30.
Signature:
Date: