Bone Closing Intake & Consent Please add your details below. PERSONAL INFORMATION Name * First Name Last Name Pronouns Email * Phone (###) ### #### Address HISTORY Date of your last birth (if applicable) MM DD YYYY Any Allergies? inc. oils, nuts, fruit. Please detail below. Additional Information If there is anything pertaining to your health, or the circumstances around your last birth you would like me to be aware of, along with any current medical conditions? EMERGENCY CONTACT Who should we contact in an emergency? First Name Last Name What number can we contact them on? (###) ### #### HAVE YOU READ THE FAQ's ON MY WEBSITE? Yes/No Yes No CONSENT This therapy is complementary to, and not a substitute for any medical treatment. These records will be treated as confidential and will not be shared with anyone. Name Today's Date MM DD YYYY Thank you!
