Moonstone Empowerment Holistic PT Client Registration Form
Welcome to Moonstone Empowerment Holistic Physical Therapy!

Thank you for choosing us to assist you in achieving your health goals. We look forward to facilitating you in your process of healing and transformation.

If at any time you have questions or concerns, please do not hesitate to contact us at

We are located in Banker's Hill M-Th and Solana Beach on Fridays:

Banker's Hill:
420 Walnut Ave
San Diego, CA 92103

Solana Beach:
312 S Cedros #206
Solana Beach, CA 92075

Contact: or (703) 627-1789

To assist us with your initial evaluation, please fill out the enclosed registration and intake forms, submit them and/or print them out and have them available for your first appointment. You may also email them to

If you are unable to keep your appointment, please notify us at least 24 hours prior to your scheduled visit.

We look forward to meeting you!

Danielle M Emhof, MPT, IMTC, Matrix Energetics Certified Practitioner
owner Moonstone Empowerment

Please fill out all pages to the best of your ability.

Email address *
First Name *
Your answer
Last Name *
Your answer
Address. Please include street address, city, state, zip code *
Your answer
What is the best phone number to reach you at? Please indicate if it is home, cell or work. *
Your answer
What is your date of birth? *
Your answer
Please list an emergency contact person, relationship, and phone number *
Your answer
Email address *
Your answer
How did you hear about us?
Cancellation Policy
24 hours notice of cancellation of an appointment is required. You may leave a voicemail message at any time of day or night. If you do not give at least 24 hrs notice you will be charged the full amount for your treatment. If less than 24 hrs notice is given, but you are able to re-schedule within the same business week, no fee will be charged. If less than 24 hrs notice is given in an emergency situation and you are unable to re-schedule within the week, it will be left to the discretion of the therapist as to whether you will be charged a partial fee of $50 or whether the fee will be waived. This charge is your responsibility; your insurance company will not reimburse this fee.
I understand this cancellation policy. *
Please sign here
Your answer
Consent to Evaluation and Treatment
I do hereby consent to the evaluation and treatment by Moonstone Empowerment. I understand it is my right to accept or refuse any treatment offered me. I acknowledge and understand that no guarantee has been made to me as to the results that may be obtained from such treatment.
I consent to evaluation and treatment. Please sign below. *
Your answer
Please list your referring physician, and your primary care physican if different. Please list name and phone number. *
Your answer
Are you under the care of a physician currently? If so please describe.
Your answer
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