You may left-click on this form to have it open up in a new browser window where you you may fill it out.  Save it and send it as an email attachment or print it out and fax it or give it to the patient.  

 

You may also right-click on the link and download the .PDF file to your computer.  You can then use it at-will.  

 

If you do not have the Adobe reader, you may simply print this page as-is.