Smart Bodywork Preliminary Client Intake

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Preliminary Client Intake

Name:*

Email:*

Phone Number:*

City:*

State:*

Company / Job Title / Brief Description of work*:

Notes (Area of need, recent injuries, surgeries, allergies, and diseases or complications)*:

Are Home & Billing the same?*

If the answer is 'No', what is the accurate billing address?:

I consent to receive bodywork support from SMART Bodywork® team (et. al.), and if ever a dispute arises, I agree to seek arbitration and/or mediation between parties rather than filing a lawsuit.*

*required field

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