• Patient Intake Form

    Patient Intake Form

    PLEASE ANSWER ALL QUESTIONS BELOW BEFORE SUBMITTING.

  • General Information

  • Format: (000) 000-0000.

  • Terms & Conditions 

    Privacy Policy

  • Birthdate*
     - -
  • Format: (000) 000-0000.
  • Have you worked with a holistic or functional practitioner before?*
  • Current doctor - What type of doctors are you currently working with? Please check all that apply:*
  • Have you previously worked with one of our practitioners?*
  • Which ones?
  • Are you seeing different health care practitioner?*
  • Format: (000) 000-0000.
  • Do you have a saturday appointment?*

  • If you clicked YES on a Saturday appointment, then please take a picture of the instructions below. The building is closed on Saturdays, so it is important you know how to access the building.

    Park in the back of the building which is the lower level and where our clinic is located. You’re welcome to park in any of the reserved parking numbers Saturday only) 43, 42, 41, or other available open spaces. 

    Proceed to the glass doors and you will see a phone on the wall to the right of the doors.
    Pick up the phone. It will start ringing.
    Say you are there for the Thermography Center Of Dallas.
    And the password is Charlie.

  • Stress & Relaxation

  • Do you relax daily?*

  • PERSONAL AND FAMILY HEALTH HISTORY

    Please fill out in detail - having your history greatly helps your practitioner serve you better!  

  • Use this link to see an example of what types of information will be useful for the question below.  

    CLICK HERE

  • Do you have children?*

  • Give a Health History for you & your Family Including; Name (First & Last), Date of Birth & Death if Applicable, Medication History, Health coonditions, Operations, & Hospitalizations. Please include; Mothers, & Fathers, Grandparents, siblings, Children, Aunts & Uncles, cousins.

     

  • Symptomology

  • Have you experienced ANY of the following?​
  • Have any of the following been removed?*
  • Have you had any Liposuction work done before?*
  • Have you had botox?*
  • Have you ever had any motor vehicle or other accidents?*

  • STRESS/EMOTIONAL HEALTH

  • Have you had any emotional upsets or traumas in your life “recently”?*

  • TOXIN EXPOSURE

  • Have you had any of the following medical imaging procedures? Please check all that apply:
  • Date of last medical imaging
     - -

  • DENTAL WORK

  • Have you had any dental work in the past 3 weeks (including cleanings)?*
  • When was your last dental visit*
     - -
  • Is your dentist holistic?*
  • Do you Have
  • Have you ever had any mercury/gold fillings?*
  • Have your amalgam fillings been removed?*
  • Do you have your wisdom teeth?*
  • Were your wisdom teeth removed?*
  • Have you been diagnosed with gum disease?*
  • Do you use a tongue cleaner?*
  • Do you floss?*

  • Water

  • Do you drink tap water from restaurants?*
  • Do you drink tap water at work?*
  • Do you shower in unpurified city water?*

  • FEMALE ONLY QUESTIONS!

    If your male skip these questions
  • Are you currently in menopause or perimenopause?
  • Are your cycles regular?
  • Are you currently nursing your child?
  • Have you experienced ANY of the following:

  • MALE ONLY

    if your a female skip these questions
  • Rows

  • Mercury

  • Rows

  • Lead

  • Rows

  • General Toxicity

  • Rows

  • MOLD

  • Rows

  • LYME DISEASE

  • Rows

  • Health History

  • Rows

  • MICROBIOME HEALTH

  • Rows

  • HEALTH PROFILE

  • Image field 200
  • Rows
  • 24 HOURS prior to your appointment, have you:*

  • Please Read and by clicking submit you acknowledge, understand and agree with the information below.

    I understand that Computerized Regulation Thermography (CRT) is not a primary diagnostic device as deemed by the U.S. Food and Drug Administration and is not to exclude other methodologies of cancer detection. Its purpose is to add information to the physician or practitioner to aid in the integration of other tests and results in order to achieve treatment outcomes, and not intended as diagnostic of any disease or dysfunction in itself. I agree to not hold the Thermography Report Writing Services responsible for any decision I or my doctor make based on the results obtained. I am ultimately responsible for payment to the Thermography Center and accept that the Center does not bill insurance companies. Payment is due at the time of service. You will be given a receipt for your visit, which you can submit to your insurance company for reimbursement. If the insurance company does not pay for the services, The Thermography Center assumes no responsibility for reimbursement.

  • Please Read and by clicking submit you acknowledge, understand and agree with the information below.

    I have requested and do hereby authorize The Thermography Center (“The Center”) or any qualified and certified agents, independent contractors, or trainees of the Computerized Regulation Thermography (Alfa Sight 9000) System to perform adjunctive diagnostic screening test with the Alfa Sight 9000 for the sole purpose of information only. I understand that The Center is not a medical facility and will not be treating me or diagnosing any medical condition. I understand that the test data or readings from this procedure will be classified and categorized by an independent party familiar with the Alfa Sight 9000 and the data will be forwarded to my chosen medical professional for interpretation and medical care intervention. Regulation Thermography is an adjunctive NOT primary diagnostic tool. I am responsible for following up with my medical care with my physician and should not rely on this procedure for the diagnosis or treatment of any medical condition. I further understand all services of the Thermography Center of Dallas operates under the umbrella of a health ministry called Abundant Grace Ministry.

    I certify that I have consulted with a representative of the Thermography Center of Dallas and have read all applicable literature given to me. I have read and fully understand all of the information presented in this Patient Consent and Release form for Diagnostic Screening. I certify that I am eighteen (18) years of age or older, of sound mind, and I am fully capable of executing this Patient Consent and Release form for Diagnostic Screening myself.

  • Confirm Today's Date and that you are Agreeing to ALL Terms Above*
     - -
  •  
  • Should be Empty: