Tikey Health New Patient Intake Form
Before coming in for a consultation, please fill out the Patient Information
and Health Assessment Questionnaire. If you are coming in for female hormone
work, please fill out the Female Hormone questionnaire. Current blood work is
required for the initial visit. If you don't have current blood work, you can
either obtain it from your Primary Care Physician (PCP) or come in for a blood
draw on a cash basis.
Please be sure to follow these directions.
- In order to receive a response to this on-line
questionnaire,
you must make an appointment.
- Fill out this form as completely as possible. Please be sure to fill out all fields from each step then select "submit". You may also save your form to your computer for later reference.
- The form will automatically submit your information through your default E-mail program.
- Please make an appointment at least 1 week after submitting this form. To do so simply call the number associated with one of the provided practice locations easiest for you.
To view our locations please select.
- Bring in all testing performed recently to the consultation. (Lab work, Xrays, Ultrasound, Bone Density Scan, etc.)
- Please be patient as the form loads and please fill out all questions listed. Thank You.
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