Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

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History of Injury/Surgery *

Check all that apply. Describe in text box below.

surgeries (i.e. appendectomy or c-section)

high blood pressure

low blood pressure

hernia

easy bruising

current fever

inflammation (chronic)

diabetes

carpal tunnel syndrome

back/neck pain

constipation

diarrhea/loose stool

spinal/disc problems

osteoporosis

osteopenia

contagious skin condition

recent accident/injury

swollen glands

headaches/migraines

decreased sensation/numbness

tennis elbow (lateral epicondylitis)

golfer's elbow (medial epicondylitis)

arthritis

cardiovascular problems

history of heart attack

history of stroke

neurological problems

blood clots/"spider veins" (deep vein thrombosis)

open sores/wounds

artificial joint

allergies/sensitivities

cancer (current or previous)

fibromyalgia

restless leg syndrome

broken bones/fractures

pregnancy

other

Preferred method of contact/follow-up *

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Text Message

Phone Call

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Cancellation Policy Agreement *

I agree to pay for full cost of session if not canceled or rescheduled within 24 hours of appointment.

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