Intake FormPlease complete & click Send: Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY How did you hear about me / who were you referred by? * Reason for Session * Brief health history (please list major accidents, surgeries, trauma and any current chronic health conditions): * Are you currently taking any medications? If so, please describe. Waiver of Liability I have reviewed and agree to the Waiver of Liability above. * Yes I have reviewed and agree to the Terms of Service and Disclaimer (links at bottom of page): * Yes Electronic Signature (first, middle & last name) * Date * MM DD YYYY Thank you!