Intake Form
After your order is completed online we will request you to sign up for a Waiver document after purchase, then fill out this form, where I can have more details needed about your health.
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Correo *
How would you rate your general health?
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Are you under a physician's care?
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Do you have any numbness or pain anywhere in your body?

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Have you had any holistic therapy before?
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If the previous answer is YES, please provide the date of last treatment
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What was it?
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Are you on current medications and/or any conditions that I should know about? *
Please tell me about any allergies or hypersensitivities *
Reason for initial visit *
Name any major accidents or surgeries (including dates) *
Name if you have any limitations or injuries
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Are you (or think you may be) pregnant?
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Do you have a pacemaker?
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Are you sensitive to touch?
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Do you prefer your session outdoors (shaded) or indoors?
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Hot or cold?
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For the aromatherapy included in your session, what do you prefer?
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If you say “yes” to essential oils, please name if you have any favorites and/or any that you absolutely dislike. If you don’t have any, I will choose intuitively for you in the session.
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Do you want to work on any specific area of concern?
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Your full name *
Phone number *
E-mail contact *
Preferred contact method *
Obligatorio

It is my choice to receive holistic therapy. I am aware of the benefits and risks of the therapy I will be receiving and give my consent for it.

I understand that there is no implied or stated guarantee of success of the effectiveness of individual techniques or series of appointments. 

I acknowledge that holistic therapy is not a substitute for medical care, medical examination, or diagnosis.

I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. 

I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

By sending this intake form, I acknowledge all information provided is real and verified.
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