Medical History
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Check the conditions that apply to you:
Cancer
Cardiac Disease
Diabetes
Hypertension
Epilepsy
Artificial Cardiac Pacemaker
None
Check the symptoms that you’re currently experiencing:
Chest Pain
Respiratory
Cardiac Disease
Cardiovascular
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Weight Gain
Weight Loss
Pacemaker
None
Are you currently taking any medication?
Yes
No
Are you currently pregnant?
Yes
No
Do you give consent for your photographs to be used?
Yes
No
POLICIES !!
I AGREE TO THESE TERMS! Cancellations in less than 24 hours before your appointment you will be charged 50% of service. 15min late to appointment will result in cancellation & will be charged 100% of the service. No Call No Shows will be charged 100% of the service. If your card on file is declined the cancellation charge will have a hold on your account and must be paid in full before any appointment date for future appointments to be approved. Card must be on file for appointment to be approved. *NO REFUNDS* *EXACT CHANGE OR CARD ONLY*
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