Patient Information

Full Name

Gender

Male

Female

Patient Age

Date of birth

Patient Occupation

City

State

Postal code

Phone *

Email *

Address

If patient is under 18 years of age, enter guardian information below.

Guardian Name

Guardian Phone

Guardian Date of Birth

Emergency Contact Information

Relationship to Patient

Emergency Contact

Emergency Contact Phone Number

How Can We Serve You?

Pain Management

Massage Therapy

Aesthetic Services

Life Coaching

Other

Pain Management

Briefly describe your pain.

HIPAA COMPLIENT

On a scale of 1 - 10, how much pain are you in?

Would you like to schedule an appointment?

Yes

No

Massage Therapy

Standard: 1-Hr Custom Massage

Add Ons

Choose below

Aroma Therapy
Hot Stones
Deep Tissue
Medi Cupping
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Would you like to schedule an appointment?

Yes

No

Aesthetic Services

Select a service.

Signature Facials

Chemical Peels

Microneedling

Non-surgical Facelifts

Life Coaching

What are your top 3 goals this up coming year?

What areas of your life do you want to improve?

Schedule an appointment?

Yes

No

All Other Requests

Please call (706)625-3585 or email [email protected]

Welcome to the Family!

We will contact you to confirm scheduling.

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