Intake Form 2
General Intake

Gloria Tucker MD 

Diplomate of the American College of Sports Medicine              

Name _________________________________________________   Date_____________

Address_________________________________________________________________

City ___________________________________State__________ Zip_________________

Email____________________________________________________________________

Phone (h)____________________________(c)___________________________*best number ?

Is it ok to leave a message that may contain personal health information ?    yes/no

Birthdate_____________________ Age_______ Sex_________

Occupation____________________________        Employer___________________

 

Whom may we thank for the referral? __________________________________________________________

(We offer 10% off for the next treatment of your referring friend)

 

Who to call in case of Emergency? ______________________________________________

Phone  Number __________________________ 2nd phone__________________________

 

Are you on blood thinners? Y/N  For what condition? __________________________

Are you interested in taking a mild pain medicine before the procedure? Y/N

If so please call us at least 48 hours before you appointment

 

IT IS VERY IMPORTANT THAT YOU READ “BEFORE YOUR PROCEDURE “AND “AFTER YOUR PROLOTHERAPY TREATMENT “ON OUR WEBSITE AT     gtucker2@gloriatuckermd.com

 

Unfortunately, Proliferative and Regenerative procedures are not covered by any insurance companies. And we require compensation at the time of service. Thank You for your understanding.

 

 

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Signature                                                                                             Date

           

© 2017 Dr. Tucker Prolotherapy and Gloria Tucker, M.D. All Rights Reserved.