MLS Laser Intake Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Preferred Method of Contact *

Reasons for seeking Laser Treatment *

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? *

Are you taking any medication that is known to increase sensitivity to light? *

Do you have any known sensitivity to MLS Laser? *

Are you or could you be pregnant? *

Do you have a seizure disorder triggered by light? *

Are you aware of carrying any sort of infectious disease? *

Do you have an HIV Positive history? *

Do you have areas of suspicious, potential, or known cancerous tissue? *

Do you have areas of active hemorrhage? *

Have you had a steroid injection in the last 2-3 weeks? *

Do you have a pacemaker? *

Are there any areas of your body where you have no feeling? *

Have you ever had a laminectomy? *

Do you have an implanted neurostimulation device (on or off)? *

Do you have tattoos? *

Submit