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Personal Details

To learn more about our non-surgical treatment options and hemp products, fill out the form below and we’ll happily get back to you. Our business hours are Monday – Friday, 9:00 am – 5:00 pm CST.

Medical Insurance

To learn more about our non-surgical treatment options and hemp products, fill out the form below and we’ll happily get back to you. Our business hours are Monday – Friday, 9:00 am – 5:00 pm CST.

Pharmacy Information

To learn more about our non-surgical treatment options and hemp products, fill out the form below and we’ll happily get back to you. Our business hours are Monday – Friday, 9:00 am – 5:00 pm CST. Please provide a Pharmacy in which all your medications are faxed, e-prescribed or called in.

Medical History

To learn more about our non-surgical treatment options and hemp products, fill out the form below and we’ll happily get back to you. Our business hours are Monday – Friday, 9:00 am – 5:00 pm CST.

Medications

To learn more about our non-surgical treatment options and hemp products, fill out the form below and we’ll happily get back to you. Our business hours are Monday – Friday, 9:00 am – 5:00 pm CST. Please list all prescription medications you are currently taking.

Tobacco, Alcohol & Drug Use

For Female patients only

Medical Release Authorization

The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for Longevity Wellness Group to share my protected health information with those listed below.

Review Of Symptoms

To learn more about our non-surgical treatment options and hemp products, fill out the form below and we’ll happily get back to you. Our business hours are Monday – Friday, 9:00 am – 5:00 pm CST. Indicate if you have or Ever had any of the following.