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- In the 'WHAT IS YOUR GOAL FOR THIS CONSULT?' section, clearly state your objectives for the consultation.
- Fill in the patient’s name, date of birth, and select whether they are a new patient or a follow-up. Indicate their gender as well.
- Provide details about the patient's occupation and any alcohol or drug use. Be specific about quantities and frequency where applicable.
- Document current and past medical history, including any behavioral therapies and hospitalizations. This section is crucial for understanding the patient's background.
- Include pertinent family history and any relevant laboratory or imaging results in the designated sections.
- Once completed, fax the form to (775) 327-5112 as instructed at the bottom of the document.
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