PATIENT INFORMATION


Can you read & understand english?

If no, interpreter contact information


Emergency contact information


Parent or legal guardian (under 18 years old)


Primary care doctor (if any)


Current medication

Are you pregnant or nursing?

Date of last menstrual period? (MM/DD/YYYY)

Drug or food allergies


Past surgical history




Privacy Policy

When you use our Products or Websites, you may be asked for personally identifiable information such as your name, address, date of birth, email address, telephone number. By giving us such information, you will need to consent to our using it in the manner described in this policy. You may withdraw your consent at any time by emailing us at info@i693registration.com. We will return or destroy your personal information within five days of receipt of your withdrawal of consent. We use personal information to allow us to process your service requests, provide access to privileged areas of the Websites, send out newsletters, personalize your visit to our Websites, personalize your use of our Products, and enable us to improve the products and services we offer. We may occasionally carry out market research and send you details of services and offers that we think may be of interest to you. If you do not wish to receive such information, please e-mail info@i693registration.com or, alternatively, when we send you an e-mail, it will contain a provision for you to opt out of receiving any further information from us.