Male Thermography Paperwork

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Age*

How did you hear about us?*

Did a doctor's office refer you?*

YesNo

Which doctor's office?

Clinical Concerns:*

Current Symptoms: *

Current Treatment:*

Current Medication: *

Any history using Thermography*

YesNo

Family History:*

Dental History:*

General Health History: *

Skin Lesions or Physical Abnormalities *

Please list all surgeries since birth and approximate date of surgery.*

Patient Disclosure

I understand that the report generated from my images is intended for use by trained healthcare providers to assist in evaluations, diagnosis, and treatment. I further understand that the report is not intended to be used by individuals for self-evaluation or self-diagnosis. I understand that the report will not tell me whether I have any illness, disease, or other conditions but will be an analysis of the images with respect only to the thermographic findings discussed in the report.

By signing below, I certify that I have read and understand the statements above and the content of the examination.

I authorize Soaak Clinics and their specially trained associate technicians of this facility to perform Thermography.

Signature