INTAKE FORM

NEW CLIENT SPECIAL!

Name

First Name

Last Name

Phone

(###)

###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

Parent or Guardian Name

(if client is under 18 years of age)

Parent or Guardian Phone Number

(###)

###

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Emergency Contact Name

Emergency Contact Phone Number

(###)

###

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Studio Policies & Waiver

I have read and agree to abide by the Studio Policies, and agree to the Participation Release Form

How did you hear about us? If applicable, who can we thank for referring you?