Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Address *Phone Number *Age *Mark Each Box if 'Yes'Are you on blood thinner?Are you pregnant or do you think you could be pregnant?Do you have or have you ever had thrombosis or bloodt clots?Do you have any open wounds or sores?Have you ever had an organ transplant?Do you have cellulitis? (NOT cellulite)Have you ever had seizures?Do you have a kidney ailment?Have you ever had plastic surgery?Do you have any type of medical device for the heart? (e.g. pacemaker)Please select any of the following conditions that apply:Emotional ChangesLyme DiseaseFlu (currently)Ulcerated ColonNeck/Spine InjuryCancerFever (currently)Elevated CholesterolInfectious ConditionsOsteoporosisAllergiesPregnancy (currently)Acute PainKidney AilmentVaricose VeinsP.M.S. SyndromeChronic PainPhlebitisHeart AilmentHigh Blood PressureTMJ SyndromeSports InjurySkin DisordersMigraineChest PainDiabetesFibromyalgiaGrief ProcessAccidental InjuryOther:Other:Please select any of these products you use that are not natural:DeodorantBody Lotions/OilsSunblockSpray TanHair ProductsOther:Other: Do You Smoke? *Yes, CurrentlyNo, but used toNo, only smoked a few timesNo, never smoked Please state any recent or past injuries or medical treatments: Please state all surgeries: (this is very important for determining the correct routing of drainage)Are you currently under the care of a health professional? *YesNoIm Not Sure If yes, please list health provider's name and phone number: determining Contact Age Emergency Contact Name *FirstLastRelationship to Emergency Contact *Emergency Contact phone Number: *Emergency Contact Email *Submit
Call Now!