New Patient Form

Please, Complete this form

Your Name*

Your Age*

Date of Birth*

Gender*

ETHNICITY*

BMI if available

Your email*

Your phone number*

Country*

General information about the consult

Please provide a detailed description of your medical history and any health concerns you may have.

Kindly include the following information:

1. A comprehensive list of all medications you are currently taking, including the dosage and scientific names of each.
2. A detailed list of all supplements you are taking, including their dosages and scientific names.
3. Your most recent blood pressure readings, including both systolic and diastolic readings, as well as your pulse rate.
4. A thorough account of your medical history and any health issues that you are currently experiencing or have experienced in the past..

Most recent blood test, Please list date

BUN

Creatinine

Glomerular filtration rate (GFR)

Potassium

Hemoglobin

Bicarbonate

Prior blood test, Please list date

BUN

Creatinine

Glomerular filtration rate (GFR)

Potassium

Hemoglobin

Bicarbonate

Urine test, Please list date

Protein

Blood

Other blood test please list

Please upload. ONLY UPLOAD PDF files

Please, upload the completed, medical form, signed and dated.

Please, upload the receipt of privacy practices, signed and dated.

Please upload any relevant blood tests, urine tests, serologies, and any imaging studies to include kidney, ultrasound, CT scan, and any other tests