Medical History

Name

First
Last

Phone

### -
### -
####

Address

Street Address
Street Address Line 2
City
Region
Postal / Zip Code
Country

Email

What is your gender?

Male
Female

Referred by

Voucher # (if you have one)

Please check

Are you currently taking any medication?

Yes
No

What medication are you currently taking?

Privacy policy

1. Cancellation Policy: We understand that unanticipated events happen occasionally in everyone’s life. It's our desire to be effective and fair to all clients, the following policies are honored: 24 hour advance notice is required when canceling an appointment. This allows the opportunity for someone else to schedule an appointment. 1.1. Fee: If you are unable to give me 24 hours advance notice you will be charged $39.00 here. This amount must be paid prior to your next scheduled appointment. 2. No-shows: Anyone who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a “no-show.” They will be charged for their “missed” appointment. No show appts using a voucher will forefit that voucher. 2.2 Fee: If you are unable to give me 24 hours advance notice you will be charged $39.00 here. This amount must be paid prior to your next scheduled appointment. 3. Late Arrivals: If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the “full” session. Out of respect and consideration to your therapist and other customers, please plan accordingly and be on time. 4. Appointments: Vouchers scheduled in the regular appointments section will be canceled or charged as regular price list. Deal Find vouchers (or other)can not be registered in place for Living Social vouchers (or other) and vice versa. Such reservations will be canceled. I agree with the Privacy policy