Forms

Forms

Medical History Form (2 pages).   For new patients who are consulting or treating with Dr. Craner:

  • Complete this form in advance of your appointment.
  • Use ONE history form for each person.
  • Either bring the completed form to the appointment, or email or fax it in advance.
    • For forms brought to your appointment:
      • Print each page ONE-SIDED (not two-sided).
      • Please print legibly.
      • Do not staple, fold, or crinkle the pages  (they need to be scanned).
      • Use a SEPARATE piece of blank paper if you need to supply additional information that cannot fit neatly on the front of the form.
    • For Faxed and emailed forms:
      • See above instructions.
      • If you are faxing multiple people’s completed forms, please fax ONE completed form per FAX transmission (e.g., if you are sending 4 family members’ forms, send 4 separate faxes).
      • Do NOT use a cover page.

 

W9 James Craner MD MPH 2016 for tax reporting purposes.