Patient History: Check all that apply to your current health as well as your past medical history.
(Female Only) Please check all that apply to you current or past medical history.
Please list the month and year of the most recent year you have had these tests performed.
Personal Physician Info:
Emergency Contact Info:
Specialist Physician Info:
Please enter the characters shown above.
(* = Required Field )
Listed below are statements that people may make about themselves. Read the list carefully and mark YES if the statement applies to you. Mark the NO if it does not apply to you. Please answer every item.
If you are not sure whether to answer YES or NO, mark whichever answer most describes you in general. *
* Please make sure you answered YES or NO to every question
I Care Clinic requires a patient to supply our medical practice with a copy of a valid state identification or U.S Passport before they may begin a therapy program. A failure to supply I Care Clinic with identification will automatically disqualify a prospective patient from receiving treatment.
If there is any person(s) in which you authorize to receive treatment or account status, please list name and relationship provided here: