Client Registration Form
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1Neuro Harmony
, LLC
Client Registration Forms
CLIENT INFORMATION:
Client Name: _______________________________________________________________________________________
(Last)
(First)
(Middle Initial)
(Nickname/Preferred Name)
Current Address: ___________________________________________ ______________ __________
____________
(Street)
(City)
(State)
(Zip Code)
Home Phone: (_____)_____________
Cell Phone: (_____)______________
Work Phone: (_____)________________
□ ok to leave detailed voice message
□ ok to leave detailed voice message
□ ok to leave voice message
□ ok to text messages
□ appointment reminders
Email Address: ______________________________________________________________________________________
Would you like appointment reminders sent to this email address? *Note emails may not be confidential*
□ Yes
□ No
Birth Date: ____/____/____
Gender: □ Male □ Female
Marital Status: □ Married □ Single □ Other ____________
Employment Status: □ Full Time Student □ Part Time Student □ Unemployed □ Employed at: ____________________
EMERGENCY/SPOUSE/PARTNER CONTACT:
Contact Name:____________________________________________ Relationship to Client
:_____________________________
(Last)
(First)
Home Phone: (_____)_____________
Cell Phone: (_____)______________
Email: ___________________________
□ ok to leave detailed voice message
□ ok to leave detailed voice message
□ ok to send appointment reminders
□ ok to text messages
□ ok to send detailed correspondence
□ appointment reminders
MINOR CHILDREN: (age of 17 and younger)
Name of Parent or Guardian: ______________________________________ Relationship to Client
: _____________________
(Last)
(First)
Address (if different than above): _____________________________ ______________ __________
____________
(Street)
(City)
(State)
(Zip Code)
Home Phone: (_____)_____________
Cell Phone: (_____)______________
Work Phone: (_____)________________
□ ok to leave detailed voice message
□ ok to leave detailed voice message
□ ok to leave voice message
□ ok to text messages
□ appointment reminders
Person responsible for these charges: ____________________________ Relationship to Client _____________________
REFERRALS:
Chose to come to Neuro Harmony or Referred to by (please check one box):
□ Doctor ____________________________
□ Insurance Plan
□ Hospital
□ Family
□ Friend
□ Location is close to home/work
□ Online Search
□ Other: _________________________________
Revised 1/27/16
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Parent category: Business