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Emergency Number
(619) 540-0875
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Patient Enrollment Form
Patient Enrollment Form
I. Patient Information
Full Name
Date of Birth
Gender Identity
Female
Male
Non-binary
Other
Preferred Pronouns
Marital Status
Single
Married
Divorced
Widowed
Occupation
Employer
II. Contact Details
Primary Phone Number
Email Address
Mailing Address
City
State
Zip Code
Preferred Contact Method
Phone
Text
Email
III. Emergency Contact
Full Name
Relationship
Phone Number
IV. Referral Information
How did you hear about us?
Website
Social Media
Friend/Family
Practitioner
Event
Other
V. Health Information
Currently under physician or mental health care?
Yes
No
If yes, please explain
Taking any medications or supplements?
Yes
No
If yes, please list
Recent surgeries, diagnoses, or major health concerns?
Yes
No
If yes, please describe
Currently pregnant?
Yes
No
N/A
History of (check all that apply):
Chronic Pain
Anxiety
Depression
High Blood Pressure
PTSD
Autoimmune Disorder
Cancer
Diabetes
Other
VI. Wellness Goals & Intentions
What brings you in today?
Primary goals for our sessions (check all):
Stress Relief
Emotional Healing
Pain Management
Spiritual Connection
Chakra Balancing
Energy Clearing
Chronic Dis-Ease Management
Autoimmune Dis-Ease Relief
Other
VII. Consent & Acknowledgement
I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease. I understand that I should consult with my healthcare provider for any medical concerns.
I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.
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Date
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