Intake Form

Please complete this form before your first appointment either online or download and bring with you. I look forward to working together.

  • Date Format: MM slash DD slash YYYY
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    Please answer the following questions:

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    Please select any of the following conditions that apply to you, past and present. Please add yours comments to clarify the condition below.

  • I understand that a Structural Integrator does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand Structural Integration is a manual connective tissue therapy and the therapist will work on muscles and fascia in a specific way to relieve tension and increase wellness. I understand that Structural Integration is not a substitute for medical treatment or medications. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status. I understand that a 24-hour cancellation is required for scheduled appointments.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.