Sign up - The Spot Treatments LLC

First and last name

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Mobile number

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Email address

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Street address

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Apt, suite, etc. (optional)

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City

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State

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ZIP code

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Practitioner/Clinic Name:

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Contact Information:

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Client Name:

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Date:

Preferred phone number:

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Best time to call:

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Email address:

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Preferred form of communication:

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How did you hear about me? (referral, Facebook, etc.)

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Description of injury/health condition:

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Possible complications/medications:

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Expected outcomes:

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Typical activities of daily living (affected by condition?):

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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

Do you have special needs I should prepare for:

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Do you have any questions or concerns:

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