Intake Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Height and Weight
How did you hear about us?
Is your goal to relax or is there a specific issue you’d like to address?
Describe your typical day. (Work, fitness, hobbies, etc.)
Are you pregnant? If so, how many weeks?
Are you taking any blood thinners or pain medications?
History of surgeries or serious injuries. Please include dates.
Please select any that apply from the list below. You may provide details in the text box.
Allergies (fragrance, contact, etc.)
Autoimmune Diseases
Breathing Issues
Cancer, History of Cancer, or Removed Lymph Nodes
Cardiovascular Issues (blood pressure, blood clots, implanted devices)
Diabetes
Mental Health Issues to be aware of
Numbness, Dizziness, or Tingling
Skeletal Issues (Arthritis or Osteoporosis)
Skin Conditions (chronic or acute)
Swelling or Inflammation (chronic or acute)
Other
Signature
Submit
Submit
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