It is very important for you to fill out these medical questions to the best of your knowledge. Our goal is to make sure that your overall health is not compromised by the treatment we provide you. All conditions and health concerns marked are confidential and follow the HIPAA Privacy Act.
Please list any medications, supplements, vitamins, or over-the-counter medications you are currently taking:
NOTE: Antibiotics (such as Penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control. I certify that I have read and understand the above questions and acknowledge that questions have been answered to the best of my knowledge.