Phone

903.784.1608

Email

info@hayesclinic.com

Opening Hours

Mon - Thurs: 10AM - 5PM , Fri: 9AM - 1PM

Hayes Clinic & Spa

Patient Information & Medical History

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Date of your appointment
Please tick all that apply

Medical History

Family Health History:

Social History:

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.
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)