PATIENT DETAILS

Date *

Patient Name *

First

Last

Date of Birth *

Sex *

Are you pregnant?

Yes
No
Not Sure

Email *

Cell Phone Number

Home Phone Number

Work Phone

Can We Leave a Message?

Home
Cell
Work

Please tick all that apply

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Patient Current or Previous Occupation *

Marital Status *

Reason For Appointment

Breast Scan
Upper Body Scan
Lower Body Scan

Is there a history of Breast Cancer in your family?

Yes
No
Not Sure

Is there a history of Lower Body Problems in your family?

Yes
No
Not Sure

Is there a history of Upper Body in your family?

Yes
No
Not Sure

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name *

First

Last

Contact Number *

Relation To Patient *

FINAL STEPS

How Did You Hear About Us?

If other, please specify

Additional Questions or Comments

“If you can’t afford prevention, how will you afford disease?”

“If you can’t afford prevention, how will you afford disease?”

Patient Intake Information

PATIENT DETAILS

EMERGENCY CONTACT INFORMATION

FINAL STEPS

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For Technician's Use

Thermographic Interpretation

Longevity Centers

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