Adult Functional Health Intake Form

Empower Health New Client Intake Form
Please fill in all of the information below honestly and to the best of your ability. This information will be kept strictly confidential, except under [the following circumstances]...
Full Name

First Name Middle Name Last Name
Birth Date

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Home Phone

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Work Phone

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Address

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Emergency Contact

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Contact's Phone

Area Code Phone Number
Relationship
How did you hear about us?

Internet Search Walked by Advertisement or Promotion
If yes to Advertisement or Promotion, which one?
I am interested the following therapies at Empower Health: (click all that apply) *

Naturopathic Services Intravenous Therapy Prolotherapy Physiotherapy Massage Therapy Breathwork Counselling Neural Therapy Natural Beauty Treatments Weight Loss Addictions Therapy Family Counselling Couples Counselling Craniosacral Therapy MELT Method Movement Therapy Other Body Work
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Empower Health New Client Intake Form

My signature below affirms that I have answered the above as truthfully and completely as possible: