Please complete this form at least three (3) days before your first appointment. I will review and contact you if I have any questions.
Please be honest with all answers, if details are left out I will be unable to provide you the best possible service.
If you answered yes to any of the questions, please be prepared to discuss your answers/diagnosis.
Answering yes to any of these questions does not always mean that you're not a candidate, but that we may need to discuss further and/or consult your doctor.