Dr. Michael Guadagnino

Chiropractic Physician

Virtual-Consultation

Intake Form

Please    

1. Fill out entire form below then hit  SUBMIT

2. Pay via the Pay Pal button below: $97 initial 20 minute consultation

3. If you need to forward any MRI reports, Past Fitness Regimens or other documentation, you will be contacted once the first two have been completed. if requested receipt will be provided so you can 

submit to your insurance company

Double click here to add text.

Pay For Consultation Here via Pay Pal

Name: Street: Town/City: State: Zip: Email Address: Marital Status: What is Your Reason for a Consultation? What do you hope to achieve from this consultation? Have You Consulted with Any Other Professional? If so, with who? Please list all the medication you are currently taking with dosage: Do you Exercise? If so how often: Work Activity: Do you follow any specific diet? Do you? Smoke Packs/Day Drink Drinks/per week Coffee Cups/day High stress Reason Put a Y next to any below to indicate you had any of the following and explain: AIDS/HIV Alcoholism Allergy shots Anemia Anorexia Appendicitis Bleeding disorders Breast Lump Bronchitis Bulimia Cancer Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Fractures Glaucoma Goiter Gonorrhea Gout Heart Disease Hepatis Hermia Herniated disk Herpes High BP High Cholesterol Kidney Disease Liver Disease Measles Migraine Headaches Miscarriage Mononucleosis Multiple Sclerosis Mumps Osteoporosis Pacemaker Parkinson's Disease Pinched Nerve Pneumonia Polio Prostate Problems Prosthesis Psychiatric care Rheumatoid/Arthritis Rheumatic Fever Scarlet Fever STD Stroke Suicide Attempt Thyroid Problems Tonsillitis Tuberculosis Tumors, Growths Typhoid Fever Ulcers Vaginal infections Whooping Cough Other: Dr. Guadagnino will not alter or critique any medications you are presently taking. You are recommended to see the advise of your prescribing physician for this advise. Please initial here that you understand: What days of the week and times (EST USA) are you available for tele-consultation? Once everything has been received you will be contacted via the email address you posted in this form as to when the consultation is scheduled. Notice of Privacy: We are required by law to protect the privacy of your information, provide this notice about our information practices and follow the information that you will receive prior to consultation: Please initial here that you understand:

Website Designed at Homestead™ List Your Business for Free