Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you experience any of the following? *

Choose all that apply

Dizziness

Headaches

Migraines

Poor memory

Moody

Bad temper

Dry Mouth

Anxiety

Panic Attacks

Depression

Acid Reflux

Nausea after eating

Loose stools

Constipation

PMS

Incontinence Urinary or Fecal

Cold hands and feet

Trouble falling asleep

Can fall asleep but can't stay asleep

None of the above

Check to confirm you've read the consent form (below)and understand the nature of treatment and cancellation policy *

I agree to pay the full price of a session if I do not comply with notifying Lorraine Lavenita L. Ac., within 24 hours before my scheduled appointment time.

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