|
Name (First Name, Last Name)
|
Today's Date (mm/dd/yyyy)
|
|
What problems originally brought you to see us? (Can't remember? You can write that here, too.)
|
Health gains you've experienced:
• • •
|
|
We would love to hear your opinions or comments regarding your experience at our office: (If nothing, you can write n/a)
|
|
|
Your doctor will record a video of them reviewing your testing and send it to you in an e-mail within 48 hours. This way, you can watch on your own time and ask any questions at your next appointment! We truly appreciate you!
|
|
