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Client Health Intake Form

Please complete the following health intake form prior to your appointment if this is your first appointment or if it has been over a year since you last completed a health intake form.

Birthday
Year
Month
Day
Multi-line address
Please Mark all that apply to you:
What pressure do you prefer?
Please check any areas of discomfort

By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform my therapist if any of the above information changes at any time.

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Date
Year
Month
Day
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