Patient Forms

Please download and fill out relevant forms then email them to Dr. Swerdloff before your visit. 

NEW PATIENT FORMS

New Patient Intake Form

Medical History – Adult

Medical History – Child

Receipt of Privacy Policy from the Practice – signature needed

HIPAA Compliance Form – signature needed

Comprehensive Medical History Questionnaire – Adult

Email Agreement Form – signature required

THERMOGRAPHY QUESTIONNAIRES 

Thermography Patient Consent

Thermography Screening Questionnaire – a history of your medical complaints

Thermography Screening Questionnaire – Breast

Thermography Screening Extended Questionnaire – Breast

Thermography Screening Questionnaire – Upper Body

Thermography Screening Questionnaire – Lower Body

Thermography Screening Questionnaire – Region of Interest

Thermography Screening Questionnaire – Full Body

TREATMENT PLAN & FOLLOW UP FORMS

Medical Diagnoses Form – track your medical problem and resolution

Supplement & Medication – track the meds and supplements you take throughout the day

Lab Follow Up Contract – signature required

HORMONE TREATMENT FORMS

Hormone Extended Questionnaire

Hormone Extended Questionnaire

Male Hair Loss Questionnaire

Greying Hair Questionnaire

METAL TOXICITY TREATMENT FORMS

Exposure To Toxic Metals Questionnaire

PAYMENT & INSURANCE RELATED FORMS

Advanced Beneficiary Notice

Medical Lien Form

Lauren Ciel Swerdloff MD Medical Corporation Inc.

DITI Functional Imaging of Santa Monica, an ACCT Approved Thermography Clinic

1821 Wilshire Blvd. Suite 220. Santa Monica, CA 90403

(310) 829-5189 | [email protected]