Page 1 of 4: Patient History Information
Do you use controlled substances?
Have you ever taken phen-phen?
Do you take a blood thinning medication?
Do you use tobacco?
Do you take insulin?
Have you ever taken bisphosphonates?
Are you allergic to any of the following?
Barbiturates(for insomnia, seizures, convulsions, anxiety)
Do you have a history of the following?
Mitral Valve Prolapse
Sexually Transmitted Disease
Are you or might you be pregnant?
Are you nursing?
Are you taking oral contraceptives?
Patient Co-Payment must be paid in full at the time of treatment. How will you be paying today? ** NO CHECKS **
To apply for Care Credit click here
Authorization and Release