" Medical Information & Consent Today's Date Time of Appointment Location Select location Manhattan ClinicQueens ClinicOutcall Therapist/Provider Select therapist AnthonyBibiCarolDiane EmmaKittLilyRuby Duration Select 60 mins90 mins120 mins Personal Information Full Name* Email* Occupation DOB Patient Phone (MRN)* Additional Phone (optional) Emergency Contact Name Emergency Contact Phone Relation Health Background Medications (list) Allergies / Sensitivities Chronic discomfort / pain What relieves it? What worsens it? Recent injuries or surgeries (with dates) Medical conditions (check all that apply) Hypertension / Cardiovascular Pregnancy (specify weeks) Diabetes Arthritis / Joint Pain Neuropathy History of Blood Clots Skin Conditions Other (please specify) Pain Map (drop pins) Score Save Delete Cancel Undo last Clear pins Pain score for next pin: 5 Signature Clear I consent to treatment and policies. Submit
