New Patient Consultation — Gordon Wong MD, MPH

Personal Information

Please complete all required fields marked with *

First Name*

Last Name*

Email Address*

Date of Birth*

Gender*

Male

Female

Other

Contact & Pharmacy

Your address, phone numbers, and pharmacy details.

Home Address

Street Address*

City*

State*

Zip*

Phone Numbers

Mobile Phone*

Home Phone

Emergency Contact

Name & Phone Number*

Pharmacy

Pharmacy Name*

Full Address with City & Zip*

Clinical History

This helps Dr. Wong prepare a thorough first consultation.

Reason for Consultation

Please describe what you are seeking help for*

Current Medications

List all medications & supplements with dosages (include OTC & herbal)

Prior Medications

Medications you have taken in the past

Family Psychiatric History

Both sides of the family, immediate and extended

Referring Provider / Therapist (optional — allows care coordination)

Name

Phone

Adolescent Section & Submit

If the patient is a minor, expand the section below. Otherwise skip to submit.

Parent / Guardian Information (for adolescent patients only) ▾

Please ensure mobile phone and email above belong to your dependent.

Parent / Guardian #1

Name

Cell Phone

Address (if different)

Parent / Guardian #2

Name

Cell Phone

Address (if different)

Before You Submit

Please double-check your email address. If you don't receive a response within 72 hours, contact gordonwongmd@gmail.com.

This form was created inside gordonwongmd.com and is HIPAA compliant.

Inquiry Received

Thank you. Dr. Wong will review your information and respond within 72 hours. Please check your email.

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