JEREMY E. KASLOW, MD, FACP, FACAAI

Print out first and then fax to 714-565-1035 (Do not E-mail)

POTENTIAL PATIENT BACKGROUND

Patient’s Name: _____________________________________ If child, list parent’s

Date of Birth: _____________________________________ names and occupations below:

Street Address: _____________________________________ ______________________

City, State, Zip: _____________________________________ ______________________

Occupation/Grade: _______________________________ ______________________

q Home Phone #: _________________________

q Work Phone #: _________________________ Fax #:_________________________

q Cell Phone #: _________________________ Email:_________________________

Please check off the one best daytime phone number and time to contact you.

Best Day(s) for Appointment: qMonday qTuesday qWednesday qThursday qFriday

Best Time of day for Appointment: q Anytime q 8-10am q Late am(10-12)

q Afternoon (1-3pm) q Late (4-5pm)

Insurance Carrier: ___________________________________________________________

Type of Insurance: qPPO qPOS qHMO qTier out of network qNone

Special Insurance Restrictions: _________________________________________

What are your out of pocket limitations: qNone

qCan’t afford anything beyond small co-pays

qCan not afford any out of pocket expenses

How did you hear about us? __________________________________________________

What major medical issues concern you? _____________________________________ _____________________________________________________________________________

Summarize your specific health goals: ________________________________________ _____________________________________________________________________________

List type of treatments you have tried: ________________________________________

How committed are you to following a nutritional program? ___________________

List any special considerations (vegan, sensitivities, etc): ______________________

______ ß Initial here to acknowledge that Dr. Kaslow is not affiliated with any HMO or medical group, payment in full at time of service is expected for Cash, Medicare, Medi-Cal, HMO, Blue Shield/United Healthcare and Blue Cross patients. Your initials also agree to pay for missed appointments and late cancellations. It is expected that you understand the basic philosophy of this medical practice.

PLEASE also fax a copy of any RECENT/RELEVANT LABORATORY REPORTS (last 3 years). If you have a brief summary of your medical needs or history, include this as well.