Brief Medical History

Please fill out and return the following form(s) to us within 24 hours of your scheduled appointment using one of these options:

  • Open the forms using Acrobat, Preview or your PDF viewer of choice. Complete them by filling in your information, and return the completed forms to us via email.
  • Print the forms and fill them out by hand, and then scan and email them back or fax them to us at 619-393-2199.
Mon - Fri : 09:00 AM - 4:00 PM | 300 Ohukai Rd, B321 | contact@revitalizemaui.com | 808-419-7445
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