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Intake Form

Personal Information
Health Information
Are you taking any medications?
Do you have any allergies or sensitivities?
Are you pregnant?
Do you suffer from any of the following? (Please tick ALL that apply):
Treatment Information
What treatment are you having?
Have you had this treatment before?

I have completed this form to the best of my ability and knowledge, and I agree to inform my therapist if any of the above information changes prior to any treatments.

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