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MLS Laser Intake Form
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Name
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Last
Email
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Preferred Method of Contact
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Reasons for seeking Laser Treatment
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Not all cases qualify for MLS Laser Therapy. Please answer all of the following and our team will follow up with you!
Are you taking any anticoagulants?
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No
Are you taking any medication that is known to increase sensitivity to light?
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Yes
No
Do you have any known sensitivity to MLS Laser?
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No
Are you or could you be pregnant?
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No
Do you have a seizure disorder triggered by light?
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Yes
No
Are you aware of carrying any sort of infectious disease?
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No
Do you have an HIV Positive history?
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Yes
No
Do you have areas of suspicious, potential, or known cancerous tissue?
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Do you have areas of active hemorrhage?
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Yes
No
Have you had a steroid injection in the last 2-3 weeks?
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Yes
No
Do you have a pacemaker?
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Yes
No
Are there any areas of your body where you have no feeling?
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Yes
No
Have you ever had a laminectomy?
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Yes
No
Do you have an implanted neurostimulation device (on or off)?
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Yes
No
Do you have tattoos?
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Submit
Home/Departments
Chiropractic
>
Our Technology
>
Pro Adjuster 360
Pro Soft 360 & MMT
Regeneration
>
Storz Shockwave
Storz Magnetolith
MLS Laser Videos
Success Stories
Neurology
>
ProBalance 360
Meet our Team
Dr. Rob
Dr. Jackie
Dr. Sophie
Dr. Zach
Geri
Peyton
Dakota
Sydney
Caitlin
Hollie
Contact Us
Patient Forms
Good Faith Estimate
HIPPA