CONSENT FORM Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Height * Weight * Referral From If no referral, how did you hear about us? Emergency Contact Emergency Contact Name * Contact Number * (###) ### #### Health Information List any medications you are currently taking, the condition associated with it, and the respective doses: * Are you currently under medical care for any reasons? Please explain: * List any allergies: * Please indicate if you have any of the following conditions and explain: High Blood Pressure, Diabetes, Tension Headaches, Joint & Muscle injuries, Paralysis, Respiratory Disease, Migraines, Areas fo Numbness, Cancer, Joint Disease, Kidney Disease, Infectious Disease, Skin Disease, Stroke, Pregnancy, Heart Disease, Areas of Chronic Pain, Aneurysm, Raynaud's disease, Blood Clot, Blood Thinner: * Thank you!
