Before your appointment

Intake form

A few details help us make your treatment safe, effective, and personal.

By submitting this form, I voluntarily consent:

  1. To inform the clinician of all allergies, current or past medical conditions or illnesses, and psychological or psychiatric conditions so that treatment or services can be safe and effective.
  2. To inform the clinician of any treatment I have had, am currently undergoing, or plan to receive in the future regarding the above.
  3. To inform the clinician if my health deteriorates or if I experience any unexplained symptoms.
  4. That I have read and understood all the details on this consent form and that the information I have provided is correct to the best of my knowledge.