• Section 1:

    Patient History: Check all that apply to your current health as well as your past medical history.

  • Section 1:

    Patient History: Check all that apply to your current health as well as your past medical history.

  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Month:Year: 
  • Personal Physician Info:

  • Emergency Contact Info:

  • Specialist Physician Info:

  • Section 4:

  • Spectrum Health Medical Spa requires a patient to supply our medical practice with a copy of a valid state identification or U.S Passport before they may begin a therapy program. A failure to supply Spectrum Health Medical Spa with identification will automatically disqualify a prospective patient from receiving treatment.
  • Patient Consent for the Use & Disclosure of Health Information

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