arcticmedicalcenter.com - Invisared Intake

Congratulations on taking your first step towards reaching your weight loss and aesthetic goals. Today you will be qualified based on several factors including medical history and your level of commitment to achieving your desired results. During today’s consultation we will evaluate your areas of concern and see if you qualify for one of our treatment programs. Your success relies on your dedication and compliance during your short time with us.

Purpose for Baseline Test - Demo Session:
1. Perform baseline test to determine your body’s response and absorption to laser light energy. 2. Demonstrate the effectiveness of our technology. Treatment protocols are individualized and specific, your program will be determined after baseline test to assure maximum results.

Demo Session Qualifications:
• Serious Candidates only.
• Must be at least 18 years of age or older.

If selected: (check appropriate box)

I would like to start a program today.After qualification, demonstration, and all my questions have been answered. I’m willing to move forward with treatment options that meet my needs and budget.I want to know more information before I commit to a program.

I consent to receiving a health screening. I realize that I am not receiving a diagnosis, treatment, or prognosis for any medical or other condition that I may be experiencing. I acknowledge that I am receiving a demonstration only and agree to hold harmless the facility, owners, employees, and any subsidiaries from any damage resulting from this demonstration. I further acknowledge that my participation is voluntary.

Print Name:

Signature:

Date:

Date

Invisared® Intake

New Patient Interview