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First and last name*
Mobile number*
Email address
Address
Apartment, suite or unit number
City
State
Postal code
Practitioner/Clinic Name:
Contact Information:
Client Name:
Date:
Preferred phone number:
Best time to call:
Email address:
Preferred form of communication:
How did you hear about me? (referral, Facebook, etc.)
Description of injury/health condition:
Possible complications/medications:
Expected outcomes:*
Typical activities of daily living (affected by condition?):
Communication Checklist (Pt. 1)*
Fees/forms of payment
Cancellation/No-show policy
Late arrival policy
Confidentiality
Communication Checklist (Pt. 3)*
Modesty/Nonsexual/draping
Food/drugs/alcohol
Oils/lotions/allergies
Have you had a fever in the last 24 hours of 100°F or above?
Yes
No
Do you have special needs I should prepare for:
Do you have any questions or concerns:
Additional Notes*