CLIENT INTAKE FORM & CONSENT TO TREAT

Name:

Date:

Address:

Emergency Contact:

Phone:

Email:

**Please answer the question below

How did you learn about us?:

Have you received any of our services before?

Yes No

Are you on any medication?

Yes No

If yes, which ones:

Any medication allergies?

Yes No

If yes, which ones:

Please mark any of the following conditions you may currently have.

Congestive Heart Disease
Infection
Lung Discase
Liver Failure
High Blood pressure
Mastectomy Lymphedema

Current Fever
Kidney Disease
Long QT Syndrome
Phlebitis
Bruises
Shortness of Breath

Recent surgery
Open wounds
Currently Pregnant
Blood Thinners
Blood Clot

Others, please specify:

*Informed consent: Patients acknowledge the risks of the procedure, including injury, infection, and death, and agree to the treatment.
*Medical advice: Providers may state that they are not giving medical advice or making claims about curing diseases.
*Disclosure: Patients are required to disclose current medications and medical conditions.
*Liability: Patients may agree to indemnify the provider from claims arising from their use of services.
*Electronic communications: Patients may consent to receiving communications from the provider electronically.
*Confidentiality: Patients may have the right to request that their medical information be communicated in a certain way.
*The information contained herein is not intended to diagnose, treat, cure, or prevent any disease.
*The services provided have not been evaluated by the Food & Drug Administration.
*It is recommended you consult you health care provider prior to starting any new medical treatments.