New Client Intake Form

To enable us to ensure your comfort and safety in every service we provide, please, take time to answer ALL QUESTIONS to your best ability. All provided information is CONFIDENTIAL and protected – we will never share it with any 3rd parties, unless required by law. Part I. Tell us about you, your goals and history of health conditions

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Address

Street Address Address Line 2 City State ZIP Code

Occupation

What is the main goal that you would like us to help you achieve? Reduce symptoms of a HEALTH DISORDER. Please specify:

Improve skin health and reduce blemishes

Improve mood, relaxation and sleep

Improve overall health and wellbeing

Assist with physical performance and recovery

Assist with weight loss and/or cellulite

Slow down and reduce signs of aging

Other

None of the above

None of the above. Please specify

Other:

Primary Physician:

Emergency Contact:(Required)

Emergency Contact Relationship:(Required)

Emergency Contact Phone Number:

How did you hear about us?

Other:

Haxx Your Body Into A Better You!

Company

Follow Us

Address

Phone Number

Hours