New Client Form If you are a new client, please fill out the below form prior to your visit. Thank you. Name(Required) Date of Birth MM slash DD slash YYYY Street Address Address Line 2 City/Town StateStateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code Country PhoneEmail Date of Anniversary MM slash DD slash YYYY Occupation How Did You Hear About Us? What is Your Goal With Today's Visit?Are You Currently Under a Doctor's Care For Any Kind of Medical Treatment? Yes No Are You Using Any Oral or Topical Medications? Yes No Please indicate any and all physical or emotional conditions you have at this time and also please update us if any changes in your physical state occur as they may affect or be affected by treatments you receive here.I understand that Serenity’s therapists do not diagnose medical conditions. I certify that I have given a complete and accurate medical history and will inform my therapist if any changes in my condition occur. I understand that the modalities used by my therapist are meant to reduce stress, tension and pain but do not replace medical treatments. We reserve the right to charge stated rates for any treatment scheduled if the appointment is missed without notice at least 24 hours in advance, and to refuse scheduling of new treatment to any individual who fails to pay for such missed appointments. Consent I Understand Typing My Name Below Constitutes a Legal Signature.Signature Today's Date MM slash DD slash YYYY CAPTCHA
