Melt That Fat Away Intake Cranial Sacral Therapy Red Light Therapy Lymphatic Drainage Book Now Melt That Fat Away Intake FormPlease enable JavaScript in your browser to complete this form.1Contact Information2Personal Information 3Health History4Weight History5Name *FirstLastAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePreferred Phone *Email *NextHeight: *Weight: *Gender: *Date of Birth: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age: *Occupation: *Hours Worked Per Week *Primary Care Physician Name: *NextAny health conditions under current treatment? *How stressed are you? Selected Value: 1 1-10 were 10 is the worstAny health conditions that affect your liver? *If yes, please explainHave you ever had cancer? If yes, please explainDo you exercise? *Yes NoHow often and what type of work out do you do? NextHow much weight do you want to lose? *Are you embarrassed about your weight/appearance? YesNoWhich parts of your body bother your the most and why? How long have your had issues with your weight? How important is weight or size reduction to you? Selected Value: 1 1-10 were 10 is the most importantAre other members of your family overweight?YesNoDo you feel tired, run down, or out of energy?YesNoPlease explainWhich do you want us to focus on? AbdomenButtocks ThighsChestArms NeckCelluliteNextAgreement: I clearly understand and agree that all services rendered are charged directly to me, and that I am personally responsible for payment. Print Name: *Signature *Clear SignatureDate *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Submit Need a Massage? Check out our openings on massages Book a Massage