👤 Patient Info
Full Name:
Date of Birth:
Sex: MaleFemaleOther
Phone: Email:
Home Address: City: State: ZIP:
🚨 Emergency Contact
Name: Phone: Relationship:
✅ Authorized Person(s) to Receive Info (Optional)
Name: | Relationship: Name: | Relationship:
🩺 Current Health Concerns / Reason for Visit
💊 Medications You’re Taking
⚠️ Allergies
🧬 Medical History (Check All That Apply)
DiabetesHigh Blood PressureHigh CholesterolHeart DiseaseAsthma / Lung IssuesThyroid IssuesSeizuresStrokeDepressionAnxietySleep DisordersChronic PainCancerOther
👨👩👧👦 Family Medical History DiabetesHeart DiseaseHigh Blood PressureMental Health IssuesCancerOther
🏃 Lifestyle Habits Do you smoke? YesNo Do you use caffeine? YesNo Do you exercise regularly? YesNo If yes, how often?
👩⚕️ Women Only Last menstrual period: Are you pregnant? YesNo Any irregular bleeding or pain? YesNo
👨⚕️ Men Only Any concerns with urination or sexual health? YesNo
✍️ Consent for Treatment I consent to receive treatment from Lakeland Cryo & Reshaping. I understand this is a self-pay service and agree to pay at the time of visit.
Date:
🧒 For Patients Under 18 Child’s Name: Parent/Guardian Name: Date:
🔐 Privacy Acknowledgment I have reviewed or received a copy of the Privacy Practices.
📅 Appointment Policy I understand that missed appointments or cancellations with less than 24 hours' notice may result in a $50 no-show fee.
Signature:
