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Medical History Form eSignature

Prénom / First Name:

Nom de famille / Last Name:

Adresse / Address:

Date de naissance / Date of Birth:

Courriel / Email:

Numéro de téléphone / Phone Number:

Carte d’assurance-meladie / Medicare Card:

Opt-in Email:

Opt-in Text Message:

Allergies:

Chirurgies antérieures / Previous Surgeries:

Tabac / Tobacco:

Drogues / Drugs:

Alcool / Alcohol:

Troubles de saignements / Bleeding disorders:

Hypertension artérielle / High blood pressure:

Diabète / Diabetes:

Cancer:

Maladies cardiaques / Heart conditions:

Troubles du système nerveux / Nervous system disorders:

Thyroïde / Thyroid:

Troubles pulmonaires / Lung disorders:

Infections sanguines (Hépatite C, VIH) / Blood-borne infections (Hep C, HIV):

Svp énumérez toutes autres conditions médicales:
Please list any other medical conditions:

Svp énumérez tous les médicaments, vitamines et produits naturels:
Please, list all Medications, Vitamins, Natural products:

Signature Date:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

5 December 2020 6 h 25 min EDT

Medical History Form eSignature Uploaded by Karl Schwarz - portal@clinique-k.com IP 173.45.30.149