Please complete this medical history form to the best of your ability. Email [email protected] if you have any questions. Thank you!

First Name *

Last Name *

Date of birth

Email *

State: (Oklahoma Residents Only) *

Please explain the reason for your visit: *

History of the following? *

No Past Medical History

High Blood Pressure

High Cholesterol

Diabetes

Cancer

Asthma

COPD

Thyroid Disease

Autoimmune Disease

Anxiety/Depression

Heart Disease

KIdney Disease

Liver Disease

Other

Specify Other:

Females:

Hysterectomy?

Or, last menstrual period:

Please list any surgeries you have had (type n/a if you have not had any surgeries): *

Please list all medications (dose, frequency and reason) you are currently taking (type n/a if you do not take any medications): *

Please list all allergies (type n/a if you do not have any allergies) *

Pharmacy Name & Address: *

Please upload most recent lab results if you have them:

Do you have any questions?

Kindly Note: A $37 service fee is collected at the time of booking. This small fee helps honor both your time and mine.

It includes:
✔️ Your initial consultation
✔️ A follow-up phone or personalized recorded video if we need to review labs or next steps
✔️ Direct access to me by email or text between appointments, should anything come up

If we find that my services aren’t the right fit for your needs,

I’ll gladly refund the fee—no pressure at all.

Please click $37 before proceeding with payment *

$ 37

*100% secure & safe payments via Square* All major credit/debit cards accepted. FSA and HSA accepted. Boggs Wellness does not save your payment information. Your payment information will not be used for any other purchase. Insurance not accepted

Please note: If you choose to pay via PayPal and your payment is not successfully processed, ensure that your date of birth is entered in the required format (MM/DD/YYYY), including the use of forward slashes