About you

We ask for your birthday and ZIP so Barb can tell whether we’ve helped you before.

First name

Last name

Date of birth

ZIP code

Phone

Best way to contact you:

PhoneTextEmailAny

Reason for your appointment

1.) Do you have a current plan:

YesNo

2.) What hospital system do you prefer:

3.) List your primary care doctor and any doctors that you would not be willing to give up

Doctor 1

Doctor's Name

Specialty

City

Phone number

Doctor 2

Doctor's Name

Specialty

City

Phone number

Doctor 3

Doctor's Name

Specialty

City

Phone number

Doctor 4

Doctor's Name

Specialty

City

Phone number

Doctor 5

Doctor's Name

Specialty

City

Phone number

4.) Complete the list of medications

People usually remember to tell me all their prescription tablets and capsules but often forget to include things like their insulin, nasal sprays, asthma inhalers, creams, and ointments. Please include all.

DON'T include medications that are otc (over the counter) or you get at the VA or that Worker's Comp pays for.

Medicine 1

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 2

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 3

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 4

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 5

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 6

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 7

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 8

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 9

Drug

Strength

Form (tab, cap, spray etc)

How often

Additional comments:

Stuck? Call Barb on (216) 287-8832.

New client form

About you

3.) List your primary care doctor and any doctors that you would not be willing to give up

4.) Complete the list of medications