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Intake Form

Personal Information

Emergency Contact Information

Doctor Information

Yoga

Female Health

HT/SI (Fire)

KID/UB (Water)

LIV/GB (Wood)

Oncology

Prenatal

SP/ST (Earth)

Well Being

Infant

TMJ (Jaw)

Conditions

Area of Complaint

Headaches

Blood

Cardiovascular

Endocrine

Family History

Gastrointestinal

Hearing

Immune

Kidney

Musculoskeletal

Neurological

Reproductive

Respiratory

Skin

Additional Information

Summary

Clinic Policy and Consent for Treatment click to view