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Medical Forms
REQUIRED FORMS:
Medical History Form for Men & Women
Or download the form in PDF. You can print, sign, and fax to 561-767-4401
ADDITIONAL FORMS:
Additional Medical History Form Women Only
You will need to print, sign, and fax to 561-767-4401
Medication Management Agreement
You will need to print, sign, and fax to 561-767-4401
Driver's License Copy
The law requires that you fax us a copy of your Driver's License to 561-767-4401
TREATMENT WILL NOT BE PROVIDED UNLESS A REVIEW OF YOUR MEDICAL HISTORY, PHYSICAL EXAMINATION, AND LAB TESTS INDICATE A NEED. COMPLETING THE REQUIRED MEDICAL HISTORY FORM, LAB WORK AND PHYSICAL EXAMINATION DOES NOT AUTOMATICALLY QUALIFY YOU FOR THERAPY WITH NEW AGE HEALTH SOLUTIONS. ONLY OUR PHYSICIANS CAN DETERMINE IF YOU QUALIFY FOR TREATMENT.