NEW PATIENT INTAKE FORM

New Patient Intake

What Service are you here to receive?




Have you ever received this treatment before?



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?



FOR WOMEN

I Am:




BY SIGNING BELOW YOU ACKNOWLEDGE AND ACCEPT THE PATIENT RIGHTS & RESPONSIBILITIES AS POSTED ON THE THRIVE WELLNESS CENTER WEBSITE

 

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