Before your first appointment, please fill out the form below and click "Submit." No printing, no pencils to sharpen; it's that easy.

Your data and personal information is safe with us. We never share or sell any data we receive, and adhere strictly to patient-therapist confidentiality. Please be advised that the treatments offered should never be regarded as an alternative to orthodox medical treatment. However, they do complement other treatments. If you are currently receiving medical treatment, please consult with your physician prior to your appointment.

Date *
Basic Information
Name *
Date of Birth *
Date of Birth
Address *
Phone *
Physician's Name
Physician's Name
Physician's Address
Physician's Address
Physician's Consent Required?
Medical History
Do you suffer from medical conditions of:
Do you suffer from allergies related to:
System Assessments
Breakfast / Lunch / Mid-Afternoon / Evening / Coffee + Tea / Alcohol
Daily Bowel Movements
Bowel Discomfort
Urinary System
Urinary System Concerns
Respiratory System
Respiratory System Concerns
Lymphatic System
Lymphatic System Concerns
Circulatory System
Circulatory System Concerns
Skin Concerns
Musculo-Skeletal System
Musculo-Skeletal System Concerns
Reproductive System - Female
Menstrual Cycle
Next Due Date
Next Due Date
Additional Reproductive System Concerns
Reproductive System - Male
Male Reproductive System Concerns
Nervous System
Nervous System Concerns
Stress Level
Energy Level
Do you smoke?
Are you commonly around people that smoke?