IMPORTANT – PLEASE READ CAREFULLY BEFORE ACCEPTING: I certify that I am a competent adult of at least 18 years of age. Should there be an early termination of services for any reason, any amount determined to be due will be refunded within 90 days. All documents, reports, and verbal or written information received from AMOWC is sensitive and confidential Proprietary Information provided to the Client for personal use only. By signing or inserting your typed name below, I agree not to, directly or indirectly, publish, disclose or otherwise disseminate such information without prior written approval by AMOWC during or after my treatment. FURTHER, I UNDERSTAND A COMPLIMENTARY CONSULTATION IS PROVIDED BY THE PHYSICIAN’S APPOINTED NON-MEDICAL REPRESENTATIVE AND IS STRICTLY TO PROVIDE PROGRAM/TREATMENT INFORMATION. ANY DIAGNOSIS AND/OR TREATMENT MUST BE MADE BY THE LICENSED PHYSICIAN DURING THE PHYSICIAN FACE-TO-FACE CONSULTATION. I certify that I have read and fully understand the contents.
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Medical History

FAMILY HISTORY INFORMATION - Please check all that apply