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.
Please write name of your referring practitioner, or Self if you are self reffered.
Phone number of referring practitioner.
Phone number of referring practitioner.
Would you like your report and images emailed to your physician or practitioner? *
If necessary, may I speak with your physician or referring practitioner? *
If none, please write none.
If none, please write none.
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.