Patient Intake Form

May we leave a detailed voicemail message and/or email:

May we send you promotional events by email:

Date of birth:

Please tick off any of the areas that you wish to discuss at your consultation:

Is there any heavy lifting with your work?

Marital status:

Any Children:

Do you have any Medical Problems:

(Example: heart, lung, kidney problems, diabetes, asthma, high blood pressure, high cholesterol, thyroid, acid reflux, anxiety, depression, bleeding, clotting, hepatitis, HIV etc.)

Are you taking Medications:

(including aspirin, anti-inflammatories, birth control pill, vitamins, homeopathic etc.)

Allergies to medications or latex:

Have you had any previous Surgeries:

Have you had any abnormal scarring:

Any reaction to anesthetics or family history of a reaction to anesthetics:

Do you Smoke?

Do you use any nicotine products (gum, patch, vaping or with marijuana)