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Intake Form
Patient Information
First name
Last name
Email
Date of Birth
Address
Emergency Contact
Physician's Name
Please check all the apply.
*
Required
Cancer
Seizure Disorder
High Blood Pressure
HIV/AIDS
Hepatitis
Skin Disease / Skin Lesions
Diabetes
Leber's Optic Neuropthy
Hormone Imbalance
Thyroid Imbalance
Blood Clotting
Any current infections / illnesses
None of the above
Do you have any of the following allergies?
*
Required
Foods / Nuts
Aspirin
Hydrocortisone
Shellfish / Animal Protein
Lidocaine
Medications
Other
None of the above
If you answered other to any question, please elaborate
Initials
I declare that the info I’ve provided is accurate & complete
Submit
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