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PROVIDING THE BEST IN TELEMEDICINE AND CONCIERGE HEALTHCARE
In Los Angeles, Orange County and Palm Springs

Contact Us Today For All Conditions

Tweet Us At:

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Pattye Anderson

Or Call Us Today!

23679 Calabasas Rd,

Suite 354

Calabasas, CA 91302

Opening Hours

24 Hours A Day!

Appointment Booking

info@slenderimage.org

Click below to download your free Healthy Weight Maintenance Guide

Weight Maintenance Guide

Consultation Form

First Name

Last Name

Patient Age

Prefered Name / Nickname

Patient Gender

Phone no.

With whome do you live?

Marital Status

Married

Unmarried

other

Marital status(other)

Occupation

Retired?

Yes

No

Date of retirement

Disability ?

Yes

No

Date of disability

Who is your primary care doctor:

Where is your primary care doctor located ?

Phone Number of primary care doctor:

allergic to any medications

Yes

No

allergic to any medications

Do you smoke?

Yes

No

How many years did you smoke?

If you quit, when did you stop?

Do you drink alcohol?

Medical Service Needed?

Prescription Needed/Changes?

Yeast Infections

Sinus Infection

High Blood Pressure

Prescription Refills

Weight Loss Clinic

Erectile Dysfunction

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