Medical Information & Consent Today's Date Time of Appointment (HHMM) Location Select location Manhattan Clinic Queens Clinic Outcall Therapist/Provider Select therapist AnthonyBibiCarolDiane EmmaKittLilyRuby Duration Select 30 mins45 mins60 mins90 mins120 mins Personal Information Full Name* Email* Occupation DOB (MM-DD-YYYY) Patient Phone (MRN)* Additional Phone (optional) Emergency Contact Name Emergency Contact Phone Relation Health Background Medications (list) Allergies / Sensitivities Chronic discomfort/pain (describe) What relieves it? What worsens it? Recent injuries or surgeries (with dates) Medical conditions (check all that apply) Hypertension/CV Pregnancy (specify weeks in notes) Diabetes Arthritis/Joint Pain Neuropathy History of Blood Clots Skin Conditions Other (please specify) Wellness Goals & Preferences Primary reason for visit Previously received holistic wellness care? SelectYesNo Areas of focus or concern Areas to avoid Preferred pressure SelectGentleModerateIntensive Preferred medium SelectOilCreamCombination Pain Map (drop pins) Signature Clear I consent to treatment and policies. Submit
