NEW CLIENT FORM

NEW CLIENT FORM
Name
Date of Birth

MonthDayYear
Date
Address
City
State
Zip Code
Daytime Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Phone Number
Format: (000) 000-0000.
Relationship
How were you referred?
Please list any known allergies
Please list any anaphylactic allergies:
Please list any medications you are currently taking:
Do you have a pacemaker?

YESNO
Are you currently pregnant?

YESNO
Payment for Services: I agree to pay Valley Allergy + Wellness the total due of services rendered by cash or credit card for each BIE clearing session.
Name
Date

MonthDayYear
Date
Signature
Should be Empty: