Electrotherapy Client Intake Form
Please complete this form to help us prepare for your electrotherapy session. Your information will remain confidential and is used only for your care and safety.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Primary Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is your primary goal for electrotherapy?
*
Do you have any of the following conditions? (Select all that apply)
*
Pacemaker or implanted electronic device
Pregnancy
Epilepsy or seizure disorder
Skin conditions in treatment area
Recent surgery
None of the above
Other
Briefly describe your current symptoms or areas of concern.
*
Are you currently taking any medications relevant to your session?
*
Yes
No
Have you received electrotherapy before?
*
Yes
No
Submit Intake Form
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