Date of Birth
ER Contact Name and Number
How Did You Hear About Us?
What Service are you here to receive?
Have you ever received this treatment before?
If Yes, what was your experience?
Are you comfortable laying on your front, back and sides
Are you comfortable with light touch and moderate pressure?
Are you comfortable with being stretched?
Are you currently under medical supervision?
If Yes, What Condition(s) and Time Frame
Please List All Rx, OTC, Homeopathic Taken Regularly
What if your Goal for this session?
Is there anything else I need to know?
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FULL LEGAL NAME
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