Client intake & informed consent 2023

Client Intake & Informed Consent Form

In the First and Last Name boxes below, enter the name of the client (the person or child who has the health issue). We will use this one name for all your records. Please use this name in all your communications.

If you’re filling this out for the client, only place your name in the box labeled, “If you are not the client, what is your name?”

First Name (As you prefer to be addressed) *

Last Name (As you prefer to be addressed) *

Is this appointment for *

You

Other

If you are not the client, what is your name?

What is your relationship to the client?

Address *

City *

Country *

State *

Zip

Email *

Phone *

Family Physician

Physician Phone

Referral

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Client intake & informed consent 2023

Great! Here's a New Subscriber Coupon you can use to get 50% off your entire order!

Enter Code: SAVE50NOWwhen you check out!

HOLIDAY MAGIC

Enter Code: SAVE50NOW
when you check out!