New Client Intake Form

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Name
Address
Date of Birth
On a scale of 1 to 10, where 10 is the worst
Which area(s) do you want us to focus on?
On a scale of 1 to 10, where 10 is the most important
I clearly understand and agree that all services rendered are billed directly to me, and that I am personally responsible for payment. I authorize Regenesis Health & Body and the Gohl Clinic to communicate with me via email, phone and SMS texts with the number(s) provided in my intake form.
Clear Signature