Personal Medical History
Please fill out the following health declaration form in order to participate in our activity. Submissions are valid up to 24 hours prior to the activity.
I. BASIC INFO
II. MEDICAL INFO
1. Has a doctor ever told you that you have (currently or in the past) any of the following health conditions?
2. Do you currently take any of the following medications?
Please provide your physician's contact information:
I request that 1st Choice Ultrasound call me at the telephone numbers listed above to schedule follow-up appointments.
I acknowledge receiving the Notice of Privacy Practices