Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Health Information

Please mark all that apply and provide any additional health information that you'd like me to know:

Pregnancy or planning to become pregnant

Cancer or terminal illness

Heart condition / pacemaker

Concussion or head injury in the last 6 months

Recent broken bones

Epilepsy

Currently taking medications

Other

By checking the boxes I agree to the following

(For Parent or Guardian if client is under 18)

I grant my practitioner permission to use light touch and the application of weighted forks on my body. I am aware that I may verbally revoke this permission before or during my session at any point.

I have provided my information to the best of my knowledge, including pertinent health information.