HYLANE™ Treatment Form

"*" indicates required fields

Personal Information

Name*

Medical Background

Lifestyles & Activities

Do you enjoy competitive activities?*
On a scale of 1 to 5, with 5 being the most ambitious, how ambitious are you?*
On a scale of 1 to 5, with 5 being the most disciplined, how disciplined are you?*
Physician fees are out of pocket, and they do not participate in any insurance plans including medicare or medicaid. Is this workable for you?*
There are usually specialty tests whose fees are directly payable to the laboratory, which are not covered by insurance, is this acceptable?*
Are you free of substance use such as alcohol or recreational drugs?*
Rate your ability to organize and follow through on tasks in your current condition:*
Eating healthy meals daily:
Finding good doctors/care:
Help with tasks you're unable to do (e.g., shopping, cleaning):