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Rooted Integrative Wellness Intake

Required Field

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Personal Info
Contact Info
Emergency Contact
Doctor
MVA history

PLEASE NOTE: The following list of conditions isn't exhaustive. Please use the "Other" fields at the bottom to provide any missing conditions or details.

Conditions/Health History
Area(s) of Complaint - select all that apply
Headaches
Neurological
Cardiovascular
Reproductive
Immune
Musculoskeletal
Gastrointestinal
Blood
Skin
Respiratory
Ear/Nose/Throat etc.
Kidney
Endocrine
Miscellaneous
Pregnancy
Medications
Injuries
Surgeries
Review & Agree