Name(required)

Email(required)

Phone(required)

Date of Birth

Genger
MaleFemale

Height

Weight

Contact Name and Number in Case of Emergency

What treatment are you interested in?

Have you had any surgery or been hospitalized in the past 2 years?
YesNo

Do you currently have, or have you ever suffered from, Allergies: food, vaccinations, drugs, hay fever?
YesNo

Do you currently have or have you suffered from Nervous Breakdown or Depression?
YesNo

Do you currently have or have you suffered from Asthma?
YesNo

Do you currently have or have you suffered from Gastrointestinal problems?
YesNo

Do you currently have or have you suffered from Epilepsy?
YesNo

Do you currently have or have you suffered from Renal problems?
YesNo

Do you currently have or have you suffered from Kidney infections/Kidney problems?
YesNo

Do you currently have or have you suffered from Blood disorder?
YesNo

Do you currently have or have you suffered from Thrombosis?
YesNo

Do you currently have or have you suffered from Thyroid disorder?
YesNo

Do you currently have or have you suffered from HIV/AIDS?
YesNo

Do you have difficulty with healing or scarring?
YesNo

Do you have any symptoms of Sensory Loss in any of your body parts?
YesNo

Have you ever been diagnosed with Cancer or Cancerous Tumors?
YesNo

Are you currently taking ANY medications?
YesNo

Estimated date that you would like the treatment?

How did you hear about our Clinic?

Comments or other requests. Please state your question for the surgeon if any.

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