top of page

Health Declaration

Please fill out the following form
in order to book a session. 

Have you been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?
If You checked The box above please Answer
If you checked the box above please answer
Respiratory Issues
Cardiovascular
Skin Issues
Head & Neck Issuses
Infections Conditions
Reproductive Issues
Family History
Neurolgical Issues
Miscellanous

Thanks for submitting!

bottom of page