Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone *

(###)

###

####

Please select which method of contact you would prefer for confirming your future appointments:

Text - the above listed phone number

Call - the above listed phone number

E-mail - the address listed below

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pervious Experience with: *

Massage

Body Wraps or Scrubs

Hot or Cold Stone Therapies

Saunas

Cupping

Reflexology

Accupressure

Acutonics

Other Sound Therapies

Chinese Medicine

Rehabilitation Therapy

Fitness Training

Martial Arts Training

Hypnotherapy

Reiki or Energy work

Chiropractic care

None of the above

Emergency Contact

(###)

###

####

Medical History

Please inform us of any medical conditions, ailments, & surgeries so we can provide you with the most accurate therapy.

adrenal fatigue

anxiety

arthritis (rheumatoid)

arthritis (osteo)

artificial joint

atherosclerosis

autoimmunity

bursitis

blood pressure High

Blood pressure Low

broken bones / fractures

bruise easily

cancer

carpal tunnel syndrome

chronic fatigue

chronic inflammation/pain

contagious skin condition

cysts/tumors

deep vein thrombosis/blood clots

depression

diabetes

fever

fibromyalgia

heart condition(s)

headaches/migraine

joint disorder

numbness/tingling/stabbing sensations

nerve damage

osteoporosis

phlebitis

pregnancy

psychiatric conditions (mental/emotional)

rashes or other skin conditions/injuries

sprain/strain

spinal issues

surgeries vascular anomalies

tendonitis

tennis elbow

TMJ

varicose veins

none of the above

other

Would you like to receive weekly newletters from iAspire on Health tips, Wellness articles, & Upcoming Therapy Specials?

Yes

No