DOT Physical Form
If this is an emergency or if you are experiencing any of the following symptoms:
Suicidal thoughts
Chest or upper abdominal pain or pressure
Shortness of breath-unable to walk across the room
Sudden dizziness, weakness, numbness, or tingling (face, arm, leg)
Sudden inability to speak
Sudden confusion, changes in mental status, or loss of consciousness
Sudden trouble seeing in one or both eyes
Seizures
Uncontrolled bleeding
Severe or persistent vomiting or diarrhea
Coughing blood, vomiting blood, or large blood in the stool
Call 911 immediately and DO NOT use Appointment Request.
*Please scroll to the bottom of the page and click continue to be able to fill out the form.
Please complete only Section 1. Section 2 will be completed by your medical provider at your exam.
New Patient Demographic Form
If this is an emergency or if you are experiencing any of the following symptoms:
Suicidal thoughts
Chest or upper abdominal pain or pressure
Shortness of breath-unable to walk across the room
Sudden dizziness, weakness, numbness, or tingling (face, arm, leg)
Sudden inability to speak
Sudden confusion, changes in mental status, or loss of consciousness
Sudden trouble seeing in one or both eyes
Seizures
Uncontrolled bleeding
Severe or persistent vomiting or diarrhea
Coughing blood, vomiting blood, or large blood in the stool
Call 911 immediately and DO NOT use Appointment Request.
*Please scroll to the bottom of the page and click continue to be able to fill out the form.