Intake

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New Client Intake Form

* Indicates required field

Name *

First

Last

Email: *

What services are you interested in? *

Craniosacral Therapy Wellness Massage Insight | Intuitive Reading Somatic Emotional Release Energetic Alignment Intuitive Mentorship & Coaching Medical Intuitive Bodyscan Other

If other please specify: *

Primary reason(s) for your appointment? *

Any other comments or healthcare concerns? *

Location for your appointment? *

Carlsbad California Portland Oregon Phone/Video Appointment Other

How did you hear about us? *

Please check each box to confirm you have read and understand the statements below:

I agree to give a minimum of 24 hours prior notice for canceling and rescheduling any scheduled appointments. If unable to give this notice, I understand that I am responsible for payment of the visit in full. This does not apply if we are able fill your appointment time with another client or in the case of an emergency.

I understand it is my responsibility as the client to provide all pertinent medical informaton and to inform my practitioners of any health history changes.

I understand that the therapies offered here are NOT a substitute for a professional medical diagnosis or professional medical treatments. I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorders.

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ilo WELLNESS - 1207 Carlsbad Village Drive, Suite J

Home
Offerings
Book online
Contact
Specials