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M Y   M E D I C A L   H I S T O R Y

So you want to be a Better Call Doc patient?

Great! We want to help you.

Follow the steps outline below.

It takes approximately 14 minutes to complete this form.

01

CONFIDENTIAL
MEDICAL HISTORY


FILL-IN BELOW

02

PRESS SEND

GOES DIRECTLY TO DR RICE'S PATIENT INBOX

03

DR RICE RESPONDS

FIRSTLY
ACKNOWLEDGES RECEIPT

THEN
SETS UP A TELEPHONE CONSULT

04

YOU & THE DOCTR

TOGETHER
YOU WILL DECIDE WHAT THE NEXT STEP SHOULD BE FOR YOUR EXAMINATION, PAIN THERAPY OR REHABILITATION

M y  C o n f i d e n t i a l 
M e d i c a l   H i s t o r y

THIS SITE IS NOT HIPPAA COMPLIANT

IT IS PROTECTED BY WEBSITE HOST ADDITIONAL SECURITY MEASURES

IT TAKES APPROXIMATELY 6 MINUTES TO COMPLETE THIS SECTION

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IF YOU PREFER TO FILL IN A PAPER FORM WE CAN DO THIS AT THE CLINIC OR WE CAN SEND YOU A FORM YOU CAN PRINT TO FILL-OUT.

ALTHOUGH WE ARE A PAPERLESS CLINIC WE WILL WILL SCAN YOUR DOCUMENT & SECURELY KEEP THEM IN OUR SECURE PATIENT SERVER.

TO REQUEST A MEDICAL HISTORY BY TELEPHONE PLEASE CALL OR EMAIL YOUR REQUEST:

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ONE MORE THING ...ATTENTION

THIS FORM DOES NOT NOT NOT SAVE A YOU COMPLETE IT. 

PLEASE BE PREPARED TO FINISH COMPLETING IT IN ITS ENTIRETY & THEN MAKE SURE YOU PRESS SEND.

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General
Gastro-intestinal
Cardio-vascular
Genito-urinary
Skin
For women only
Respiratory
Have you eve been diagnosed with:

Upload any medical record you think we may want to review like written medical report, x-ray, MRI, CT Scan, ultrasound, blood work / urinalysis. You can always jsut bring the documents with you when you visit the clinic.

UPLOAD documents here

The Academy has received your admissions form.

Please allow for 3 business days to hear back from us

by email. Looking forward to our chat.