Thank you for using My Crystal Clinic to access your very own secure patient medical health history form!
To ensure that we have an accurate health history, we ask that you
complete this one-time through our secure link to the right.
Your medical health history process will include a series of questions related to the categories below:
- Your Identification Information -- Name, Address, Birth Date
- Medical History
- Surgical History
- Social History
- Pharmacy (Address, Phone Number)
After clicking the Continue button (above), you will provide responses to a series of questions
that will help us to assess and determine your plan of care during your office visit. Please complete
every answer on each page prior to clicking the 'Next' button.
Your thorough and complete answers on the next few pages will help our Physicians and staff
provide you the excellent care you deserve.
Thank you for choosing
Crystal Clinic, Inc.!