Travel the world.

John D. Wilson, M.D.
1200 Hilyard St., Ste. 560
Eugene, Oregon 97401 USA
fax 541.485.7702

Patient Registration Form

Each traveler needs to complete the Registration Form and bring it along to the appointment.

If you do not already have this useful program, please DOWNLOAD FREE the latest version of Adobe® Acrobat® Reader® onto your hard disk.   This will allow you to print an exact copy of the questionnaire.
  1. Download the questionnaire to your screen by clicking either image below.
  2. When the form appears on the screen , choose Print from the File menu, then OK..
  3. Please print and fill in both pages of the questionnaire for each person in your group to bring to the office with you at the time of your visit.

Clicking on either page of the form downloads both pages.


Click Adobe's Troubleshoot PDF printing for help in troubleshooting printing problems with PDF files.


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©  John D. Wilson, M.D. 1999-2017; Last Update 10/18/2017