All appointments are non refundable unless canceled w 72 hours notice
Prior to completing this evaluation form, please review our Notice Of Privacy Practices. It is important that you understand your rights as a patient and acknowledge that you have reviewed the notice before we can begin treatment.
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. I authorize BOMAMED to contact me regarding treatment, appointments, payment or other health related information in the following manner:
Please indicate those that are current health for your self and your family members with a "C" under appropriate person's column. "P" should be used to indicate a past problem. Leave blank those that do not apply to you.
How often you eat the following:
Please include vitamins, herbs, supplements, and prescriptions medications
Please include cigarettes and other tobacco products.
Please select your symptoms from the following list:
Dr. Brizman's dissertation
"Treating Interstitial Cystitis with an Integrative Model of Classical Chinese and Western Medicines"
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