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New Client Intake Form

Please fill out the following form in order to confirm your appointment
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Medical History
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Tell me more
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Acknowledgement
By signing this form, I acknowledge that the methods used to gather information during my appointment are complementary tools to help understand my overall health. They are NOT to diagnose, treat or cure, and are NOT a replacement for any standard methods of evaluation or a physician's exam.
Except in cases of emergency, I agree to
pay for 50% of my appointment's fee if cancelled within 24hrs.
Policies
  • Except in cases of emergency, I agree to pay for 50% of my appointment's fee if cancelled within 24hrs.
  • Except in case of emergency, I agree to pay 100% of my appointment's fee if I do not show up for my appointment.
  • Cancellation and no show policies apply to the Gift Certificates.

You may not be able to sign this form if you are using your cellphone.

In this case, skip the signature section and submit your form. 

Thanks for submitting!

Lou Piché
Traditional Thai Massage
Natural Health & Nutrition Consultant
Holistic Allergy Testing
wildnesshealing@gmail.com | 778.348.7348 | www.wildnesshealing.com