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)



    Do you have any questions or would like a personal consultation?