Patient Form

Fields marked with * are required fields.
If a required field doesn’t apply to you, type no or n/a.
Questions? Call 530-926-1731

*LAST NAME

 *FIRST NAME

 MIDDLE INITIAL
*ADDRESS

 APT#

 OCCUPATION
*CITY

 *STATE

 *ZIP
*HOME PHONE

 *WORK PHONE

 *EMAIL
*BIRTH DATE

 *AGE

 *SEX

    M

    F
NAME OF FAMILY PHYSICIAN

 PHONE

 *REFERRED BY
*WHAT IS THE REASON FOR YOUR VISIT/CHIEF COMPLAINT?
*ARE YOU CURRENTLY ON BLOOD THINNING MEDICATION?

    Yes

    No
 *DO YOU BRUISE EASILY?

    Yes

    No
DOMESTIC STATUS

    Married

    Single

    Divorced

    Widowed
Name of Partner (if applicable)
DO YOU EXERCISE REGULARLY?

    Yes

    No
HOW MANY DAYS PER WEEK?
DO YOU FEEL YOU NEED TO CHANGE YOUR DIET?

    Yes

    No
WHEN WAS YOUR LAST ACTIVE RELEASE TECHNIQUES TREATMENT?

    I’ve never had one before

CANCELLATION POLICY:

Appointments canceled without a 24 hour notice will be charged a $75.00 cancellation fee.
I HAVE READ THE ABOVE INFORMATION AND CERTIFY IT TO BE TRUE TO THE BEST OF MY KNOWLEDGE.
I UNDERSTAND THAT PAYMENT IN FULL IS EXPECTED AT TIME OF VISIT AND I AGREE TO THE TERMS ABOVE.


    Yes, I Agree
    Here are my Initials:

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