Pre-Appointment Check-In

Language / Idioma

Patient Information

Full Name

Date of Birth

Date of Service The date of your appointment.

Your Location During the Appointment

Actual Physical Address Where You Are Currently Located Enter the complete street address of the location from which you will attend this appointment. Do not enter a mailing address unless you are physically located there.

City

State

ZIP Code (if known) Enter your ZIP Code if you know it. You may leave this field blank.

Insurance Information

Have there been any changes to your insurance coverage?

No changes Yes, there are changes

Medication and Allergy Information

Active Medications List every medication you currently take, including the name, dosage, and how often you take it. Include prescription medications, over-the-counter medications, vitamins, and supplements.

I am not currently taking any medications or supplements.

Allergies List medication, food, environmental, or other allergies and describe the reaction, if known.

I have no known allergies.

By submitting this check-in, you confirm that the information provided is accurate and complete to the best of your knowledge.

1. Click Send to Dr. Story.

2. Wait for “Sent to Dr. Story” to appear on this page.