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Starting at $35/hr for Individuals and $70/hr for Couples

Assessments

First Name:
Last Name:
Address:
City:
State:
ZipCode:
Phone:
E-Mail:
Primary Goal for Care:
How did you hear about us?:
Conditions: Headaches Cancer Fibromyalgia Arthritis
Colitis PCOS Athlete's Foot Skin Rash
Acne Thyroid(Hyper/Hypo) Diabetes Blood Clot
Dandruff Auto Accident Slip & Fall Bruise
Recent Surgery Ringworm Poison Ivy/Oak
Torn Ligament/Muscle Heart Problems Heartburn
Seasonal Allergies Sinusitis Common Cold/Flu
High Blood Pressure Digestive Problems Sunburn
Shingles Other

Comments / Questions:

Areas to concentrate more care:

Areas to avoid:


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