Evoke Healing Space - Laser Therapy Patient Intake Form

Laser Therapy Patient Intake Form
Are you a candidate for laser therapy?

Laser therapy is an FDA cleared modality for the treatment of pain and inflammation and the temporary increase of microcirculation. Laser therapy can provide relief for many acute and chronic conditions. This form is a tool to help your clinician determine if you are a candidate for laser therapy. If you answer yes to any of these questions you will need to discuss details of your condition with your clinician.
Please check YES or NO to the questions below.
Do you have a pacemaker or any other implanted device?

YESNO
Are you pregnant?

YESNO
Do you have cancer?

YESNO
Are you taking medication that may increase your sensitivity to light?

YESNO
Have you had a steroid injection in the last 7 days?

YESNO
Any Additional Notes We Should Be Aware of?
The ultimate decision to recommend treatment lies with your health care provider.

Speak with your health care provider if you have further questions about therapy treatment.
Patient Name:*

First NameLast Name
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: