Please click on the link(s) below to download forms for your appointment. Filling these forms out in advance will ensure you enjoy more time with your therapist and also makes it easier for you to fill them out accurately.
Please call 239.307.5616 with questions.
FORMS FOR MASSAGE CLIENTS:
Health History and Client Information Form
FORMS FOR THERMOGRAPHY PATIENTS:
PREPARATION INSTRUCTIONS:
Please download and read How to Prepare for Your Thermogram prior to your thermography appointment!
It is important that you do not schedule thermography immediately following therapy such as massage, acupuncture, chiropractic, etc. Also plan to not workout or have prolonged exposure to sunlight or heat prior to your scan. You may also visit our webpage to read these important INSTRUCTIONS on How to Prepare for Your Thermogram
INTAKE FORMS TO DOWNLOAD:
ALL PATIENTS:
Patient Info Questionaire
PER APPOINTMENT TYPE:
Breast Questionnaire history form (Required for Breast Scan)
Full Body Questionnaire form – download if needed
Upper Body Questionnaire form – download if needed
PHYSICIAN/CLINICIAN REFERRAL FORMS:
Please note, a physicians referral is not needed to schedule thermography. Physicians are welcome to use these forms to give thermographer specific instructions.
Doctor Requisition Form for Breast Scan
Doctor Requisition Form for Pain Evaluation
FORMS FOR THERAPEUTIC DEVICES:
Avazzia Microcurrent Session or Demo