Patient paperwork

Complete your health history, informed consent, and liability waiver before your visit. Available for adults signing for themselves. For a minor or someone signing through a representative, contact our team.

If you have questions about treatment or the documents, speak with your clinician before signing. Do not use this page for urgent medical concerns.

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1. Health history

Full legal nameDate of birthPhonePreferred appointment date (optional)

Service addressEmergency contact — name, relationship, and phone

Medical history

Heart disease / heart failureHigh blood pressureKidney diseaseLiver diseaseDiabetesAsthma / lung conditionSeizuresClotting / bleeding disorderAnemia / G6PD deficiencyFluid restrictionCancer / active treatmentFainting with needlesOtherNoneDetails, dates, and any fluid restrictionsSurgical history — procedures and dates, or “None”Daily medications and supplements — name, dose, and frequency, or “None”Allergies — medications, foods, latex, adhesives, or ingredients and reactions, or “None”Pregnant or breastfeeding?Current symptoms, recent illness, vomiting, alcohol use, or dehydration — describe, or “None”Requested service (subject to clinical review)Intake initials: I confirm my health information is accurate, complete, and current.

2. Informed consent

Read the full document. Please contact us with questions before signing.

Printed legal name — informed consentI have read and understand the informed consent, had the opportunity to have my questions answered, and voluntarily agree. I intend the signature method selected above to be my electronic signature on this document.

3. Risk acknowledgment and liability waiver

Initial each risk

Arbitration initials: I have read, understand, and agree to the arbitration agreement in Section 10.Printed legal name — risk acknowledgment and liability waiverI have read and understand the risk acknowledgment and liability waiver, had the opportunity to have my questions answered, and voluntarily agree. I intend the signature method selected above to be my electronic signature on this document.

Service-specific risk acknowledgments

For each treatment listed, choose whether it is planned for this visit. Read its additional risks in Exhibit A above and initial each planned treatment. Your clinician will confirm the treatment plan.

Printed legal name — service-specific risk acknowledgmentI have read and understand the service-specific risk acknowledgment, had the opportunity to have my questions answered, and voluntarily agree. I intend the signature method selected above to be my electronic signature on this document.

4. Optional photo permission

This single selection applies to the optional photo/video clauses in both documents. Declining does not affect your ability to request service.

Photo, video, and social media permissionI have reviewed the photo/video terms in both documents and confirm my selection above.

Your signatures will be stored with the exact document text and submission time. A staff member will review this paperwork; the clinician and witness portions are completed separately before treatment.

Patient paperwork

Medical history

Initial each risk

Service-specific risk acknowledgments

Paperwork received