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INTAKE FORM
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Please complete intake form prior to appointment.
INTAKE FORM
Full Name (first & last)
Date of Birth
Email
Phone
Address
Service requested:
Are you a Member?
*
The MONALISA
The Elite
The VIP
No, I'd like more info!
Medical History (check all that apply)
Recent surgeries (date)
History of blood clots
History of cancer
History of bruising
Abnormal breathing
Use of blood thinners
Lymphedema
Hernias
Open of infected wounds
Sensitivity to cold or hot
Hypertension
Irregular Heartbeat (EKG)
Ankle Swelling
Kidney Disease
Diabetes
Uncontrolled Anxiety
Congestive Heart Failure
Known Allergies
Explanation of Medical History
Consent to Service: I consent to the above service(s) and have notified my provider on this form of any other concerns/issues that may impact my desired service(s).
SUBMIT
Intake Form Completed. Thank you.
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