AVUM Health Consultation Intake

Secure Patient Intake

Please complete the information below so our team can prepare for your consultation and verify your patient profile.

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address

Street Address

City

State

Country

Postal Code

Height

Weight

Sex Assigned at Birth

Do you have any medical conditions we should be aware of?

Are you currently taking any medications or supplements?

Do you have any allergies? *

Government-Issued Photo ID

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 5 Files )

Upload Front and Back of Health Insurance Card (optional)

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PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 4 Files )

Consents & Acknowledgments

By checking this box, I consent to receive non-marketing text messages from AVUM Health regarding appointments, intake forms, laboratory orders, treatment updates, and patient care coordination. Message frequency varies. Message and data rates may apply. Reply STOP to opt out.

I understand that AVUM Health provides telehealth wellness consultation services. I certify that the information provided is accurate and complete to the best of my knowledge and understand that treatment recommendations, if appropriate, are determined after provider review and consultation.