Treatment Release Form This form must be filled out prior to receiving treatment. If this form is not filled out prior to arrival, treatment will be denied until the form is submitted.Name* First Name Last Name Phone*Email* Do your legs swell and stay swollen even upon waking up in the morning?*YesNoDo you experience chest pain with walking up to two blocks?*YesNoDo you experience shortness of breath with walking up to 2 blocks?*YesNoDo you experience shortness of breath with lying flat?*YesNoDo you have to stack up more than 1 pillow when lying flat in order to not feel short of breath?*YesNoDo you bleed easily and are unable to stop bleeding?*YesNoDo you have swelling of the abdomen, legs, face or arms?*YesNoDo you have unexplained bruising on your body?*YesNoHave you noticed urine that is foamy?*YesNoHave you had blood in your urine recently?*YesNoHave you ever had an allergic reaction to the any of the ingredients of the injection you are requesting?*YesNoAre you pregnant or is there the possibility you are pregnant?*YesNo This iframe contains the logic required to handle Ajax powered Gravity Forms.
