Pre-Appointment Check-in

How to Complete and Send This Form

1. Complete all required fields on this page.

2. Click the blue “Open Email to Submit Check-In” button at the bottom of the form.

THE BLUE BUTTON DOES NOT SEND THE FORM. It only opens your email application. You must then press SEND inside your email application.

3. Your email application will open with a message addressed to drstory@atomicshrink.com. Your completed information will already be copied into the email.

4. Review the email and press SEND inside your email application. The office will not receive this form unless you complete this final step.

Patient Information

Full Name

Birthdate

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.

Why Your Current Physical Location Is Required

Telehealth services are delivered with the patient and healthcare professional participating from different locations. Your healthcare professional must confirm where you are physically located at the time of service to determine whether care may legally be provided in that jurisdiction and to coordinate emergency assistance if an urgent safety or medical situation occurs.

Please provide the address where you will actually be located during this appointment, even if it differs from your home or mailing address. Location requirements may arise from federal telehealth guidance, state professional-licensing laws, payer requirements, and the healthcare professional’s emergency procedures.

Federal telehealth information is available through the U.S. Department of Health and Human Services .

Insurance Information

Have there been any changes to your insurance coverage?

No changes Yes, there are changes

Please explain the insurance changes Include the insurance company, plan, member identification number, or other information that changed.

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.

IMPORTANT: After the email opens, you must press SEND inside your email application. Clicking the blue button alone does not send this form.

By continuing, you confirm that the information provided is accurate and complete to the best of your knowledge.