If a completed copy of this form were given to Dr. DeVito on your first visit, it would help in the efficient assessment of your condition and in the planning of your treatment.  On it please list any major health problems for which you have been treated in the past, as well as any current conditions for which you are seeking treatment.  Also indicate any medications which you are currently taking and any allergies that you may have.

You can either view and print a copy of the form or download a copy of it in Microsoft Word or Adobe Acrobat (.PDF) format by clicking the appropriate button below.

 
Word Format .PDF Format
 

      

 

Please print a copy of this form and bring it with you on your first visit. This is a federally mandated form which must be completed by all patients in order for medical practitioners to properly comply with patient non-disclosure laws.  You must sign this form in front of Dr. DeVito before she can treat you.

You can either print a copy of the form or download a copy of it in Microsoft Word or Adobe Acrobat (.PDF) format by clicking the appropriate button below.

Word Format

.PDF Format