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

Preferred Pronouns (optional)

Contact & Pharmacy

Your address, phone numbers, and pharmacy details.

Home Address

Street Address*

City*

State*

Zip*

Phone Numbers

Mobile Phone*

Home Phone (optional)

Emergency Contact

Someone Dr. Wong may contact in a clinical emergency if needed.

Name*

Relationship*

Phone*

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

Before You Submit

Please double-check your email address. After you submit, you'll continue with the consent and policy forms — your name, date of birth, email, and phone will carry forward automatically.

If the patient is a minor, parent/guardian details are collected in the separate Consent to Treat a Minor form later in the intake.

Information Received

Thank you. Your intake information has been saved.

Next, please complete the consent and policy forms. Your name, date of birth, email, and phone will pre-fill on the next forms automatically.

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