Client Consent Form Client Consent Form Personal InfoName(Required) First Last Date Of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemaleOtherContact InfoMobile Phone(Required)Email(Required) Address(Required) Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency ContactEmergency ContactEmergency PhoneRelationship Client Medical HistoryHave you been treated by a physician within the past year for any health conditions? What is your physician's name? Are you currently taking any medications? Have you had any surgeries in the past? Is it possible that you might be pregnant? YES NO Are you currently breast feeding? YES NO What are your present complaints? How did you hear about our service? Please check off any conditions with which you sufferHeart and Circulatory SystemHeart and Circulatory System High Blood Pressure Chest Pain Stroke Swelling/edema High Cholesterol Murmur Anemia Heart Disease Palpitations Bleeding Disorder Genitourinary SystemGenitourinary System Urinary Retention Prostate Disease/BPH Kidney Disease Menstrual Problems Bladder Disease Respiratory SystemGenitourinary System Asthma Sinus Disease Tuberculosis Bronchitis COPD Shortness of breath Pneumonia Emphysema Gastrointestinal SystemGastrointestinal System Ulcer Vomiting Acid Reflux Constipation Nausea Gall Bladder Disease Neurologic SystemNeurologic System Headaches Dizziness Weakness Paralysis Psychiatric Disorder Migraines Numbness/Tingling Fainting Depression Multiple Sclerosis Concussion Epilepsy/Seizures Balance Problems Anxiety Leber’s Hereditary Optic Neuropathy Musculoskeletal SystemNeurologic System Arthritis Joint Problems Bone Problems Muscular Dystrophy Other Chronic Medical ConditionsOther Chronic Medical Conditions HIV/AIDS Cancer Hepatitis Thyroid Disease Diabetes Review & AgreeReview(Required) HIPPA FORM Review(Required) Infusion-and-Injection-Informed-Consent-Form Review(Required) B12-and-Lipotropic-Injection-Consent-Form Review(Required) Telehealth/Telemedicine consent Review(Required) Indemnification clause Review(Required) Payment and Cancellation Policy Signature(Required)
