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Client History Form

If you are a first time client, please fill out the form below. 


 

Your Information:

Required


Required
Required



 

Personal Identification:

Birth Date:
Upload photo of Drivers License:
(Front)
(Back)
Upload photo of Medical Card:
 

General Medical History:

Check the box if you have, or have had, recent problems with any of the following:
 

Additional Information:

Any additional notes or medical issues I should be aware of:
 

 


 

 

Quesnel BC

250-740-5645

peachysthaimassage@gmail.com