LivingInFlow Wellness Pre-Session Intake Form / Formulario de Ingreso Previo a la Sesión

LivingInFlow Wellness Pre-Session Intake Form / Formulario de Ingreso Previo a la Sesión

Please complete this form before your session. All information is confidential. / Por favor complete este formulario antes de su sesión. Toda la información es confidencial.
Do you know which therapist you want to see?
Full Name / Nombre Completo

First NameLast Name
Phone Number / Número de Teléfono
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth / Fecha de Nacimiento

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact Name / Nombre del Contacto de Emergencia
Emergency Contact Phone Number / Número de Teléfono de Contacto de Emergencia
Please enter a valid phone number.Format: (000) 000-0000.
Medical History (Check all that apply) / Historial Médico (Marque todas las que correspondan)

Other / Otro
Fill In For Other
Purpose For Coming
Release of Liability / Exoneración de Responsabilidad
I hereby release Eduardo Aguilar and Livinginflow Wellness from any and all liability, claims, demands, or causes of action
arising from participation in training or massage therapy services, except in cases of gross negligence or willful misconduct.
I grant permission for Livinginflow Wellness to use photos or videos taken during sessions for marketing purposes, unless I indicate otherwise below.
I want to receive messages (In Home Scheduling, Offers and Upcoming Events)
Signature
Should be Empty: