All of your information will remain confidential between you and Dr. Corey Howard.
Please take your time filling out this questionnaire completely and honestly.
There are duplicate questions throughout the form- Please answer each section completely
Age, Significant Health Problems
Last Date Done & Results (-/+)
Including cosmetic and/or weight loss procedures
ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPPA PRIVACY ACT
THIS FORM IS CONFIDENTIAL AND HIPPA APPROVED