SHOTS FOR HEALTH AND HCG HISTORY FORM

Please fill out this history form. (First Time Only)

After submission you will be taken to the purchasing page.

Name: *

Date of Birth (MM/DD/YYYY): *

Address: *

Cell Phone Number: *

Email Address: *

Medication Allergies *

If Yes, Please Specify:

Reason For Shot: *

Other, Please List:

If Autoimmune Ds, Please Specify:

Other Medical Ds: *

Other, Please List:

List Current Medications Taken: *

Person Giving Shot(s) & Qualifications, If Any *

Shot Type(s): *

Patient's Name Entered Verifying Information Is True: *

Physician's Signature Or Authorized Associate:

How did you hear about us? *

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