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)


     
    footer-image-1

    WE WELCOME YOUR
    QUESTIONS & COMMENTS

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

    CONTACT US