Bowen Therapy Intake Form
Thank you for you interest in the Bowen Technique. Please fill out the following intake questions 2-3 days prior to your initial appointment. To read more about the conditions that Bowen can address, visit: www.dynamicmedicine.net/the-bowen-technique/conditions/
Name (first, last) *
Email
Phone Number
Please provide the best number to use for scheduling purposes
Age
Sex
Occupation
Sports/hobbies/activities
Previous operations/accidents/illnesses: *
Please record dates and details. Please make special care to note any breast/pec implants or reconstructive jaw surgery, both of which are contraindicated with certain Bowen Procedures.
Presenting Conditions: *
Primary Health Goals *
In what area(s) do you want to see the most improvement? What signs and symptoms would you most like to resolve? What does your healthiest self look like? Please be as specific as possible.
Prior Treatment for Presenting Conditions *
Please note that, because of the subtlety of Bowenwork and the body's continuing response to it, other forms of MANIPULATIVE THERAPY performed up to four days before, or five days after, a Bowen session may interfere with its effectiveness.
Required
Other Relevant Comments:
Informed Consent
I request and consent to Bowen treatment with Carol-Ann Galego. I understand that no promise or guarantee of specific results can be made. I understand that Bowen treatment should not be considered as a replacement for treatment by a Medical Doctor.
I have read and understood the above consent for myself and/or my child. *
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