General consultation form

First name

Last name

Phone

SMS subscribe

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Please leave instructions for parking. I am caring heavy equipment, so FREE immediate parking is required

Heart condition

Yes

if Yes, elaborate more

High or Low Blood pressure

Yes

if Yes, elaborate more

Diabetes

Yes

if Yes, elaborate more

Skin disorders

Yes

if Yes, elaborate more

Medications

Yes

if Yes, elaborate more

During hemotherapy or radiotherapy

Yes

Short answer

Allergies

Yes

if Yes, elaborate more

Cancer

Yes

if Yes, elaborate more

Loss of skin sensation

Yes

if Yes, elaborate more

Bruises

Yes

if Yes, elaborate more

Pregnancy

Yes

if Yes, elaborate more

Epilepsy

Yes

if Yes, elaborate more

Recent scars or surgeries

Yes

if Yes, elaborate more

Phlebitis

Yes

if Yes, elaborate more

Medical Odema

Yes

if Yes, elaborate more

Please upload Doctor's notes, if you have specific medical condition you answer with YES above or if your doctor requires adaptation on your treatment or proof of parking

Upload your file

Choose a file or drag and drop one here.

I agree to terms and conditions and I confirm that the information given in this form is true

I agree to inform immediately, if my body temperature is getting higher than 37 °C, develop a cough or loose my sense of taste and smell in the last 24 hrs prior the treatment

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Month

Day

Year

General consultation form

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Please leave instructions for parking. I am caring heavy equipment, so FREE immediate parking is required

Heart condition

Yes

if Yes, elaborate more

High or Low Blood pressure

Yes

if Yes, elaborate more

Skin disorders

Yes

if Yes, elaborate more

During hemotherapy or radiotherapy

Yes

if Yes, elaborate more

Loss of skin sensation

Yes

if Yes, elaborate more

Recent scars or surgeries

Yes

if Yes, elaborate more

Medical Odema

Yes

if Yes, elaborate more

Please upload Doctor's notes, if you have specific medical condition you answer with YES above or if your doctor requires adaptation on your treatment or proof of parking

Upload your file

Choose a file or drag and drop one here.

I agree to terms and conditions and I confirm that the information given in this form is true

I agree to inform immediately, if my body temperature is getting higher than 37 °C, develop a cough or loose my sense of taste and smell in the last 24 hrs prior the treatment

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.