Mobile Medtox Client Intake Medical Form

Personal Profile and Client Medical Intake Form
Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

Other
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about us?

Other
What part of your body do you want services performed?
What services did you want to get today?
Medical Condition
Have you had any of these services before?
When was the date of your last treatment?

MonthDayYear
Date
Are you pregnant?
Are you breastfeeding?
Do you exercise regularly?
Are you currently taking any medications ? If yes, please list all of them below and what they were prescribed for.
Do you have any allergies? If yes, please list all of them below.

Do you have any of the following?

Do you feel any pain on any part of your body? If yes, which part?
Acknowledgment
Signature
Date Signed

MonthDayYear
Date
Certifications
Choose all you certify to be accurate
Signature
Signature
Date

MonthDayYear
Date
Liability Waiver
I acknowledge that this activity may result in personal injury or medical complications. I hereby release Mobile Medtox, its affiliates, injectors, successors, or assigns from any current or future liabilities or claims, including but not limited to medical fees and personal injury. Additionally, I authorize Mobile Medtox to make medical decisions on my behalf if needed or if an emergency contact person cannot be reached.
Signature
Your Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Patient Information