Phone

903.784.1608

Email

info@hayesclinic.com

Opening Hours

Mon - Thurs: 9AM to 12:30PM, 1PM to 5PM Fri: 9AM to 1PM

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Hayes Clinic & Spa

Patient Information & Medical History

Date
Appointment Date
Date of your appointment
Patient Name
Can We Leave a Message?
Please tick all that apply
Mailing Address

Medical History

Please check if you have any of the following:
Immunizations:

Family Health History:

Mother (Please check all that is applicable):
Father (Please check all that is applicable):

Social History:

Estimated current exercise level:
Example: Feel compelled to eat because of stress.
DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Notice of Privacy Practices:

Hayes Clinic 520 N Collegiate Drive Paris, TX 75460 License Number: H 9983 Effective Date: April 1, 2003
DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Click or drag files to this area to upload. You can upload up to 2 files.
Please upload photo documentation or a screen shot of your Smart Scale weight reading that includes your weight, fat percentage, etc.
Click or drag a file to this area to upload.
Please upload a clear photo of your state issued ID or Driver’s License.
A smart scale is required for all initial TeleMed weight loss appointments.
Click or drag files to this area to upload. You can upload up to 3 files.
Please upload your lab work. Lab work should include: Lipid Panel, Thyroid Panel (Including Free T3), BMP (Basic Metabolic Panel)