Consultation Intake Form

Norspring

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Consultation Intake Form

Please complete the form below and take the first step toward receiving your personalized wellness plan.

Name

Phone

Which services or treatments are you seeking consultation?

P.E.M.F Therapy (BEMER) Hyperbaric Oxygen Chambers First Time Injections Laser Hair Removal Hormone Therapy Female Hair Loss General Wellness Aesthetics Personal Training Weight Loss

Which services, treatments, or benefits interest you?

Longevity Increased Energy Skin Health Hair Health Weight Loss Anti-Aging Pain Management Cryotherapy Red Light Therapy Infrared Sauna Physical Recovery Personal Training

Are you experiencing any physical pain?

yes no

If you answered yes please let us know where on your body you experience pain.

Are you currently recovery from a sports injury or surgery?

yes no

If yes, please indicate what happened:

Are you experiencing any of the following:

Trouble sleeping Fatigue or lowered energy Headaches Weight gain Rapid weight loss Unwanted fine lines or wrinkles None of the above

Which Norspring location is best for you?

Please let us know any other important information or concerns you may have regarding your wellness or aestethic goals.