Advice Request Advice request Your name * Relationship * Patient Spouse Adult child Friend OtherOther Best phone * Email * Permission / Disclaimer “I give permission to Dr. Stall to review the information contained herein and render advice. I understand that information transmitted via this form and Dr. Stall’s response via email is not HIPAA compliant i.e. may not be secure.” Consents * Yes, I agree to the Permissions / Disclaimer Consents * I am the patient, or a legal health care agent for the patient Main concerns * Care needs increased / overwhelming Frequent falling Gradual decline in health status New/worsening memory problem Possible medication side effect / too many medications Sudden decline in health status OtherOther Details of main concerns * Captcha Payment If you are human, leave this field blank. Δ
