Medical History

  • So that we may provide you with the best possible care please complete this form as accurately as possible. If you need assistance or have any questions please feel free to ask us.
    **All information is strictly confidential**

  • Have you ever had any of the following? Please check the appropriate boxes.

  • To the best of my knowledge, all of the preceding answers are correct. If I have any change in mymedical condition or my medications I will inform Dr. Hughes and his staff at my next appointment.
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  • We wish our patients to know that all professional services rendered are charged to the patient and that patients are responsible for payment of fees. Insurance is a contract between you and your carrier. A service charge of 1.5% will be added monthly to all outstanding balances after 60 days. If your account is referred to a collection agency for non-payment of fees, the fees incurred will be added to your balance and will become your responsibility.
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