Client Intake-Tendedrootswellness

First Name

Last Name

Email

Phone Number

Address

Emergency contact name and phone #

Occupation

Date of birth

Are you military or a first responder?

Yes

No

Have you had craniosacral therapy before?

How did you hear about Tended Roots Wellness?

What issues are you dealing with that require the most attention at this time?

What are your treatment goals?

Are you taking any medications?

Do you have any allergies?

Are you pregnant?

Yes

No

Do you have any autoimmune disorders? If so, please list.

Do you experience any of the following?

Please list any other concerns, complaints or pertinent information.

Please allow a minimum of 24 hours notice if you need to cancel or reschedule out of respect for my time and other clients. In the instance of a last minute cancellation or no show appointments please understand you will still be charged for the appointment.

I agree to the terms & conditions

Date

Your Signature

*