new client information form
craniosacral therapy bodywork Jenny Miller, LMT MA92253
Email address *
Name *
Cell Phone Number *
Address *
Emergency Contact Name & Cell Phone *
How did you hear about Jenny Miller?
How did you hear about craniosacral therapy?
How do you feel today? *
History of trauma, injury, or surgeries.
Current illnesses, diseases, or medical conditions?
Current medications and reason for taking them?
Do you have any pain? Where? How often?
I consent to receiving craniosacral therapy from Jenny Miller. I know that she is a Licensed Massage Therapist in the State of Florida and cannot diagnose any physical or mental condition. Craniosacral therapy should not be considered a replacement for treatment by a doctor or other medical professional.
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