HEALTH FORM Please complete the information requested in this form and press the “Submit” button at the bottom. By submitting this form I acknowledge that this information is true and correct as of this date, and I give my permission for Dr. Hang to communicate with other healthcare professionals regarding treatment recommended. Please be assured all information submitted will be held in strict confidence.
Please describe any medical, dental or surgical problems not covered above
Names and ages of siblings if patient is a minor