This below form must be completed for all new and existing clients.

Name *
Name
Cell Phone *
Cell Phone
Please include area code.
Home Phone
Home Phone
Please include area code.
Referring physician
Would you like your report and images emailed to your physician or practitioner? *
If necessary, may I speak with your physician or referring practitioner? *
Name of practitioner or physician.
Name of practitioner or physician.
Phone number of your practitioner.
Phone number of your practitioner.
Patient Disclosure *
PATIENT DISCLOSURE I understand that the Report generated from my images is intended for use by trained health care providers to assist in evaluation, diagnosis and treatment. I further understand that the Thermography Report is not intended to be used by individuals for self-evaluation or self-diagnosis. I understand that the Report will not tell me whether I have any illness, disease, or other condition but will be an analysis of the Images with respect only to the Thermographic findings discussed in the Report.