Thank you for taking the time to complete this Consultation Form.
The following information will be used to help plan a safe and effective treatment for you. Please answer the questions to the best of your knowledge. All information shared in this form is kept in the STRICTEST OF CONFIDENCE. For insurance purposes, if you currently have a medical condition, I would really appreciate it if you could download the enclosed Doctor Consent Form and get it signed by your doctor to confirm that it is OK for you to have a treatment. Bring it along with you when you come for your appointment 🙏🏽.