Are you eligible for our Hero Discount Program? Verification (such as ID, license, discharge paperwork, etc) will be required.
N/A Military (including active, retired, and Reserve forces) First responder (including police officers, firefighters, EMTs, and paramedics) 911 operator RN or LPN with active nursing license Correctional Officer Border Patrol Agent
List any discontinued medications and the corresponding dose* If none, type "n/a" or "none"
List any current medications and the corresponding dose* If none, type "n/a" or "none"
Please list any known allergies* If none, type "n/a" or "none"
Please list any surgical procedure(s)s and approximate date(s)* If none, type "n/a" or "none"
Please list any or all anesthesia problems with you or your family members* If none, type "n/a" or "none"
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Please list all current or resolved conditions regarding Neurological/Brain conditions (stroke, epilepsy, concussions, etc.)* If none, type "n/a" or "none"
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Please list all current or resolved conditions regarding Cardiac/Heart conditions (high blood pressure, heart attack, heart murmur, etc.)* If none, type "n/a" or "none"
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Please list all current or resolved conditions regarding Gastro/Liver/Intestinal conditions (Crohn's, IBS, hepatitis, etc.)* If none, type "n/a" or "none"
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Please list all current or resolved conditions regarding Endocrinology (cancer, diabetes, thyroid, etc.)* If none, type "n/a" or "none"
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Please list all current or resolved conditions regarding Renal/Kidney conditions (renal failure, dialysis etc.) If none, type "n/a" or "none"
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Please list all current or resolved conditions regarding Pulmonary/Lung conditions (asthma, COPD, tobacco use, etc.)* If none, type "n/a" or "none"
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Please list all current or resolved conditions regarding Orthopedic/Bone conditions (fractures, rheumatoid arthritis, osteo-arthritis etc.)* If none, type "n/a" or "none"
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Please list all current or resolved conditions regarding other conditions (fibromyalgia, pain syndromes, chronic pain, glaucoma etc.)* If none, type "n/a" or "none"
List any non-prescribed and/or illicit drug use* If none, type "n/a" or "none"
Did a current patient refer you to KWC? If so, please enter their name below so that they may benefit from our referral program.
Did a medical professional refer you to KWC? If so, please list their name/practice below.