Patient Intake Form

All information on this form is strictly confidential.

Please complete all information in the following form. It may seem long, but it is all very important information that is required to provide the best quality of care. 

This information is mostly used to organize your thoughts prior to your appointment.

Dr. Edwards will ask similar questions and many more during your initial evaluation.

NOTE: Dr. Edwards sees patients ages 10+ and adults across the lifespan.

Thank you!

Read through our office policies and FAQ

before filling out the form below.

Patient Intake Form
Please include medication name, total daily dosage and estimated start date.
Please indicated the dates, dosage, and how helpful they were. If you cannot remember all the details, just write in what you do remember.
Do you have or have you had any? Please list them.
Selected Value: 0
Use numer slider to indicate the amount of days 0-7

IMPORTANT:

If you click the “SUBMIT” button above and the form does not submit, please look for the skipped fields outlined in red.

Once you fill out all of the required fields, the form will be sent directly to Dr. Edwards’ office.