Pre-visit packet

Personal profile and consent forms

Please complete every section before signing. Your specialist will review the answers before treatment.

Personal profile

Enter the information that will be inserted into the final Personal Profile form.

First name * Last name * Middle initial Date of birth * ID attachment Use a clear image of a passport, driver's license, or other official ID. Email * Cell phone * Home phone Work phone

How did you hear about us? Other / details

Form details

These answers are inserted into the forms. Final agreement happens after you review the full document package.

Authorized contact

Add a person only if you want the clinic to be able to share appointment or treatment information with them.

Authorized person for appointment information

Communication preferences

Phone, SMS, and email are required for appointment, follow-up, and treatment-related communication. Other message options are optional.

Call my cell phone * Leave voicemail on my cell phone Send text messages (SMS) * Send emails * Leave messages with spouse/partner Leave messages with receptionist/co-worker

Clinical documentation and optional media

I understand clinical photos, video, or audio may be used when needed for treatment documentation, planning, safety, quality review, or medical record purposes. * Optional: I separately authorize educational, website, social media, or marketing use only as described in the final optional media section.

Review details

Check the information that will be inserted into the forms. Use Edit if you need to correct an earlier section.

Client summary

Review forms and sign

Review the full consent and policy form text below before confirming and signing.

Form preview will appear here

Complete the previous steps to generate the consent and policy form preview.

Printed name *

Draw signature *

not submitted

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