Health Intake Form

feel the difference

Name

First Name

Last Name

Cell Phone

(###)

###

####

Text

Yes

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

mm | dd | yyyy

Occupation

Allergies

Emergency Contact

List name and relationship

Emergency Contact Phone

(###)

###

####

Serious or chronic illness, surgeries, or traumatic accidents

Medications

Please explain where you're feeling pain or tenderness

I consent to and authorize Authentic Healing Myofascial Release LLC to Clinical photographs/videos for clinical measurement and documentation purpose. These materials will be kept in clinical records and protected by all private policies and procedures.

Yes

Cancellation Policy Acknowledgment

Check box once you've read and agree to the cancellation policy

Cancellation Policy: Appointments not canceled 24 hours in advance will be charged in full to the card on file.

How did you hear about us?

I have completed this form to the best of my knowledge

Check box once you've read and agree

I understand the services provided are designed to be a health aid and in no way takes place of a doctors care when it is indicated. Information exchanged during any appointment is education in nature and is intended to help me become more aware of my own health status. It is to be used at my own discretion.

E-Signature

This will be considered your legal signature.

Date

mm/dd/yyyy