Your Name (required) Bus Phone (required) Res Phone (required) Address City State Zip Who referred you? Are you under a doctors care? yesno Health Problems CancerEpilepsyHeartAllergiesArthritisVaricose VeinsHeadachesHigh/Low Blood PressureCardiac or Circulatory problemsContagious DiseasesJoint Swelling Do you? Bruise easilyWear Contact LensesSuffer from StressHave Back PainPregnantSkin DisordersAny Tension or SorenessAny surgery or injuries in the last 2 yearsHave Numbness/Stabbing painSensitive to touch or pressureHave any medical conditions I should be aware of Your Email (required) Comments
