Ask Dr. Stall 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 Appointment request * Medication review Memory assessment Wellness visit Appointment not needed at this time OtherOther Information available Medication list Test results Other Documents to upload Current primary care physician - name phone (e.g. Dr. Smith 999-999-9999) 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 * Current medications - name strength frequency (e.g. lisinopril 10mg once a day) Test results - date test result (e.g. 3/2/16 tsh 6.2) Other information Documents to upload (upload all documents in one file) Drop a file here or click to upload Choose File Maximum upload size: 67.11MB If you are human, leave this field blank.