Name *

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Do you experience any of the following? *

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Dizziness

Headaches

Migraines

Poor memory

Moody

Bad temper

Dry Mouth

Anxiety

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Acid Reflux

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Constipation

PMS

Incontinence Urinary or Fecal

Cold hands and feet

Trouble falling asleep

Can fall asleep but can't stay asleep

None of the above

Check to confirm you do not currently have COVID19 and you have not experienced fever, coughing, shortness of breath, loss of smell or taste OR have not quarantined with anyone with these symptoms in the last 14 days. *

If you or someone you live with has been exposed to COVID 19 in the last 14 days, I kindly ask that you reschedule in at least 7 more days.

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Check to confirm you've read the consent form (below)and understand the nature of treatment and cancellation policy *

I agree to pay the full price of a session if I do not comply with notifying Lorraine Lavenita L. Ac., within 24 hours before my scheduled appointment time.

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