Miramas New Patient Request

Miramas Health - New Patient Request Form

Please let us know more about you and your health concerns.
Full Name*
First Name Last Name
Gender*

Male Female

Address

E-mail*
Phone Number
- Area Code Phone Number
Birth Date*
Month Day Year
What are your most important health issues that you would like us to help you with? Please list them all in order of importance.*
Which doctor would you like to see as a patient?

Dr. Loretta Kershaw Dr. William Alvarez Whoever is first available
What type of appointment would you like?*

At the clinic By telephone / skype
How did you hear about Miramas Health Clinic

I am a previous patient of Miramas Health I was referred by a patient of Miramas Health I was referred by someone who is not a patient of Miramas Health I found out on my own (internet, yellow pages, advertising) Other
What are you goals for yourself and your condition?
Why did you choose to come to Miramas Health?
What makes your condition feel better or worse?
What is your level of commitment? How dedicated are you to making the changes necessary for health?
Please check any potential obstacles do you foresee in addressing the changes or following the protocols that are recommended by Dr. Kershaw?

I don't like taking pills I can't afford much treatment I am too busy I have to hide this from my family Other
Who will sincerely support you during this program and encourage the lifestyle changes and protocols that you will be making?
If you currently have a contagious disease, please list it below.
Please let us know about the last time you received medical or health care.

Please indicate how often you visit the following health care professionals.

Please describe any factors that may be contributing to your stress.
Add any additional information that you think may be useful for the doctor to know about you and your case.
Thank you for completing our survey. We will review your request and you will be contacted shortly with the next steps.
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Miramas Health - New Patient Request Form