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Name
First Last
Age
Date of Birth
Date Format: MM slash DD slash YYYY
Email

example@example.com
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Last
Phone Number
Relationship
Health Data
Do you have any allergies?
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Are you pregnant or nursing? (Female only)
If yes, please specify on the field above.
Have you been recently hospitalized?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
If yes, please specify on the field above.
Location of painful areas
Consent and Waiver
Consent
I authorize Wizdoms Wellness to perform the treatment or necessary procedure for my child.
Consent
I authorize the use of lotion, oil, and ointments to my body.
Consent
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
Consent
I release Wizdoms Wellness for any responsibility in case of an accident, illness, or injury.
Consent
I acknowledge that all information I provided int his form is true and accurate.
Signature
Date Signed
Date Format: MM slash DD slash YYYY