Male Thermography Paperwork

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Age

How did you hear about us?

Did a doctor's office refer you?

Which doctor's office?

Clinical Concerns:

Current Symptoms:

Current Treatment:

Current Medication:

Any history using Thermography

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