new client information form

By submitted the form below I consent to receiving craniosacral therapy from Jenny Miller. I know that she is a Licensed Massage Therapist in the State of Florida (License No. MA92253) and cannot diagnose any physical or mental condition and that craniosacral therapy should not be considered a replacement for treatment by a doctor or other medical professional. I also understand that Jenny is willing to work in cooperation with my healthcare professionals.

[contact-field label="First & Last Name" type="name" required="1"/][contact-field label="Email" type="email" required="1"/][contact-field label="Cell Phone Number" type="text" required="1"/][contact-field label="Address" type="textarea" required="1"/][contact-field label="Emergency Contact Name & Cell Phone" type="textarea" required="1"/][contact-field label="How did you hear about Jenny?" type="textarea" required="1"/][contact-field label="How did you hear about craniosacral therapy?" type="textarea" required="1"/][contact-field label="How do you feel today?" type="textarea" required="1"/][contact-field label="History of trauma, injury, or surgery?" type="textarea" required="1"/][contact-field label="Current illnesses, diseases, or medical conditions?" type="textarea"/][contact-field label="Current medications and reason for taking them?" type="textarea"/][contact-field label="Do you have any pain? Where? How often?" type="textarea" required="1"/][/contact-form