MEDICAL HISTORY FORM

Please provide the information requested below, to the best of your ability. Once you've completed the form, a member of patient outreach team will get back to you as soon as possible.

If you have any questions or comments please contact Elizabeth Garcia, patient coordinator, at elizabeth@giostarchicago.com. You can also reach us at 844 446 7827

MEDICAL HISTORY FORM (2 of 5)

Please use date picker or enter in format mm/dd/yyyy; e.g., 11/05/1963

Street Address

Street Address Line 2 (e.g., Apt., Suite)

CityState / Province

Postal / Zip Code

Weekdays during the morning (09:30 AM-12:00 PM CST)Weekdays during the afternoon (1:00 PM-3:30 PM CST)Saturdays (10 AM-2 PM CST)Flexible (all options work for you)

Type "None" if you have no allergies

MEDICAL HISTORY FORM (3 of 5)

MEDICAL HISTORY FORM (4 of 5)

MEDICAL HISTORY FORM (5 of 5)

I understand that a deposit is required to lock in any promotional pricing.I understand that if, for any reason, I must cancel my appointment on the scheduled appointment date, I am subject to forfeiting half of the total procedure cost, which will include the security deposit, for the procedure.I understand that I must give 2 weeks notice if I need to cancel my scheduled appointment. Failure to do so will subject in losing the amount paid.

Type "None" if not applicable.

Medical History Form