Women Only Are you:
Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.
Please mark "Yes" if you have (or have had) any of the following diseases or problems.
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.