Phone

903.784.1608

Email

info@hayesclinic.com

Opening Hours

Mon - Thurs: 10AM - 5PM , Fri: 9AM - 1PM

Hayes Clinic & Spa

Patient Information & Medical History

//
//
Please make sure that you are selecting the correct year of your birth.
Please tick all that apply

Medical History

MIC LIPOSLIM Consent Form

Injection Components: Thiamine HCl 50 mg Riboflavin-5-Phosphate 10 mg Dexpanthenol 5 mg Methylcobalmin 1mg (1000 mcg) Vitamin C 50mg Choline Chloride 25 mg Carnitine 50 mg Methionine 12.5 mg Niacinamide 15 mg Pyridoxine HCl 5 mg Methyl-Folate 1 mg (1000 mcg) Inositol 25 mg Crhomium Picolinate .1mg Lidocaine 5 mg **The main ingredients in Hayes Clinic & Spa's MIC LIPOSLIM injection include Choline Chloride (amino acids), inositol (a vitamin-type nutrient), and vitamin C.**
DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.

Notice of Privacy Practices:

Hayes Clinic 520 N Collegiate Drive Paris, TX 75460 License Number: H 9983 Effective Date: April 1, 2003
DISCLAIMER: By typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form.
Click or drag a file to this area to upload.
Please upload a clear photo of your state issued ID or Driver's License.