Confidential Health History Form printable pdf download

Confidential Health History Form

Name:

Date of birth:

Single

Married

Life Partner

Divorced

Widowed

Address:

City/State/Zip:

Home Phone:

Cell Phone:

Email Address:

Would you like to receive coupons, news and updates through our eNewsletter? Yes

Subscribers may unsubscribe at any time. Newsletter goes out monthly, birthday coupons are annual.

In Case of Emergency Contact:

Relationship & Phone:

Family Physician:

Phone:

How did you hear about us?

Occupation:

Hours per week:

On a scale of 0 (none) to 10 (unmanageable), how stressful is your:

Work?

Health status?

Social/family situation?

Policies:

Payment – we accept cash, checks, and all major credit cards. Returned checks will incur a $30

charge payable to The Barefoot Dragonfly within 10 business days. Payment is due at time of

service.

Cancellations – we value your business and make a commitment to you to guarantee your

appointment time and refuse all other requests once you have made the appointment. A 24

hour cancellation notice is required for any scheduled appointment. You may be charged up to

the full amount of the session booked if notice is not given 24 hours in advance. Missed or no-

show appointments will be charged the full amount of the treatment booked. Gift certificates

are forfeited and marked redeemed with less than 24 hours cancellation notice, or for a missed

or no-show appointment.

Policies: Please initial that you have read the above policies: _____________________

The Barefoot Dragonfly•11673 Jollyville Rd, Suite 201 • Austin, TX • 78759 • 512-666-9374 •

Confidential Health History Form