Buhler Athletic Injuries & Human Perform. Clinic
447 North 300 West Suite #5
Kaysville, UT 84037
8015442355

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information

Contact Information
How did you find out about our office?
Current Symptoms

Personal Health History
Family/Primary Physician
Please list any health conditions that you have been treated for in the last year:

List current medications

List current vitamins, minerals, supplements, or herbs

Social History & Life Choices
Reason for this Visit
Please briefly describe, including the impact it has had on your life.
For Women Only
COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.
Health Problems & Concerns
Authorization
Signature
Finalizing Form