CranioSacral Therapy Intake Form

Required Field
Personal Info
Contact Info
Emergency Contact
Doctor

Confidentiality:

You have a certain privacy expectation as well as rights and our practice is fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPPA) privacy and security rules for health care providers. We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. Please review and sign the HIPAA Right To Privacy Notice Form with more detailed information. Attached as a separate document.

 

 

Health Questions
Characters: 0/255
Characters: 0/255
Characters: 0/255
Characters: 0/255
Characters: 0/255
Characters: 0/255
Characters: 0/255
Characters: 0/255
Characters: 0/255
Characters: 0/255
Contraindications to CST - Check with practitioner
Characters: 0/255
Characters: 0/255
Characters: 0/255
Characters: 0/255
Characters: 0/255
Review & Agree