• Weight Loss Red Light Intake Form

  • PERSONAL INFORMATION

  • Date
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  • Format: (000) 000-0000.
  • Date of birth
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  • Who may we thank you for referring you to our office?

  • MEDICAL HISTORY

  • Rows
  • Are you taking any medications/supplements?
  • Are you breast feeding?
  • Any known allergies?
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  • What would be different or better without this/these concerns?
  • How have you addressed weight management in the past?

  • Please rate on a scale of 1-10 (1 being the lowest and 10 being the highest)

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  • I AM INTERESTED IN

  • In medicine today, leaky gut aka intestinal permeability, isn't typically diagnosed. However that doesn't mean it's not affecting your health. Many health issues related to LGS go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please take the quiz to help our doctors evaluate how we can help your condition and any underlying triggering limiting your health in process.

    Let's get started.
    Please select any that apply to you prior to taking the quiz below:

  • Hormone imbalance including:
  • Gastrointestinal issues including:
  • Respiratory Conditions including:
  • Autoimmune Conditions including:
  • Developmental and social concerns including:
  • Skin Conditions: (urticaria)

  • Please complete our TYG wellness quiz. While there's more to it than a single quiz, the answers below can give you a good idea of how happy your gut really is. Select the number that most closely fits, then add up your results.

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  • INFORMED CONSENT FOR DAHLIA

    RED LIGHT THERAPY

  • This consent to treatment form explains the risks and benefits of the Dahlia Red Light

    Therapy treatments. Patient understands the following:

    1. Results vary greatly from person to person. No result is guaranteed.
    2. Dahlia Red Light Therapy is a treatment intended to be implemented in conjunction with a modification in diet and lifestyle as part of a complete protocol. The recommended diet and lifestyle is a critical part of the program and are essential in achieving the maximum results.
    3. Temporary hyperpigmentation/hypopigmentation (changes in skin color) on rare occasions may occur as a result of treatment.
    4. Light therapy has no known contraindications. However, Dahlia does not recommend treatments for patients who are under the age of 18 (without parental consent), who are pregnant, or who have active skin or other cancers (active or within 1 year of remission).

    By signing below, patient agrees that Paramount Health may perform the Dahlia Light procedure for the purpose of body contouring. Patient understands and accepts the risks listed above and agrees that all information on this form is true and correct to the best of patient’s knowledge.

  • Date
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