THE WELL @

The Fernando Chiropractic and Wellness Center, LLC

Dr. Antonio C Fernando

NAME _________________________________________________ DATE________________

ADDRESS ____________________________________________________________________

DOB _______________________________

WORK PHONE_____________________HOME/CELL PHONE_________________________

EMAIL _______________________________________________________________________

MARITAL STATUS S M D SP

EMERGENCY CONTACT_______________________________ PHONE_________________

OCCUPATION______________________ EMPLOYER_______________________________

REFERRED BY: GROUPON PATIENT/CLIENT OTHER_________________

AREAS OF THE YOUR BODY YOU ARE INTERESTED IN RECEIVING LASER LIPO TREATMENTS:

CHIN ARMS ABDOMEN LOVE HANDLES BACK THIGHS HIPS BUTTOCKS

CURRENT WEIGHT _________________ GOAL WEIGHT ____________________

CURRENT DRESS / PANT SIZE _______________ GOAL SIZE __________________

WHEN WAS THE LAST TIME YOU WERE YOUR IDEAL WEIGHT / SIZE? ___________

HEALTH HISTORY

ARE YOU PREGNANT Y N

BREASTFEEDING Y N

DO YOU HAVE A PACEMAKER Y N

ANY METAL IN THE AREAS OF

TREATRMENT Y N _____________________

ANY OTHER MEDICAL HISTORY YOU WOULD LIKE TO SHARE AND INCLUDE WITH YOUR FILE? EX: HEART, LIVER, KIDNEY DISEASE, ETC.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ANY MEDICATIONS? __________________________________________________________

OFFICE POLICY FOR MISSED APPOINTMENTS:

Clients are allowed two (2) missed appointments to re-schedule. After that, missed appointments will be forfeited. Additional treatments are charged at full price of$50.00 per treatment. Please call 24 hours in advance.

AUTHORIZATION TO TREAT:

I, ___________________________________ hereby authorize Dr. Fernando  to administer such treatments as is necessary.  I hereby certify that I understand the advantages and possible complications. I also certify that no guarantee or assurance has been made as to the results that may be obtained.

Client Signature __________________________________________ Date _________________

Dr. Signature ________________________________