Please call me (see 'About Me' page) or complete form below.
The minimum requested information is -
Name, phone, and email...
The additional information would be most helpful, however,
and will expedite my service to you.
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Client Data Sheet
First and Last Name
City and State
Date of Birth --- Sex
Tobacco user? YES / NO
Meds currently taken (and dosages), for what condition, and what year diagnosed.
Height / weight
FOR DISABILITY ONLY: Occupation / duties; NET monthly income (self-employed); GROSS monthly income (if employee)
Any comments you wish to add