Intake Form for Elite Laser Therapy

Please, take your time filling out this form. It is imperative that we have accurate information to be able to complete a thorough assessment and help us purse the best course of action.

How often are you experiencing symptoms?
Are your symptoms:
Whom have you seen for your symptoms?
Diagnostic testing?

Check if experiencing conditions

PLEASE ANSWER THE FOLLOWING QUESTION:

Are you Pregnant?
Do you have a pacemaker or any other medical transplant equipment?
Do you suffer from Encephalopathy?
Are you hypersensitive to powerful light energy?
Are you taking any performance-enhancing drugs?
Are you using corticosteroids or any other steroid therapy?

I have answered the above questions to the best of my ability. I understand that this information will only be used to help provide me with the most accurate and best care.

Thank you for taking the time for filling out this form accurately and completely. We truly value your health and this form will help guide us in assessing your personal treatment plan.

Address:

679 Sierra Rose Dr. Suite B

Reno, NV 89511

Phone:

775-722-0884

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