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Home
About
About Ubuntu
Meet Our Team
Careers
Services
Clinical Services
Massage Services
Fitness & Yoga Classes
Specialty Classes & Workshops
Reiki & Raindrop
Kids & Teen Wellness
Training & Professional Education
Workplace Wellness
Gift Cards & Packages
Contact Us
Book Now
Holistic health services to enhance your mind, body and spirit.
Download Our Intake Packet
Patient Information
Patient Name:
*
Patient's Phone Number:
*
(###)
###
####
Mother's Name (if minor):
Mother's Phone Number:
(###)
###
####
Father's Name (if minor):
Father's Phone Number:
(###)
###
####
Guardian (if minor):
Guardian's Phone Number:
(###)
###
####
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address:
Can we use this email address to notify you of upcoming appointments?
Yes
Social Security Number:
*
Date of birth:
MM
DD
YYYY
School Name (if minor):
School Contact:
School Contact Number:
(###)
###
####
What is the preferred way to contact you?
Phone
Email
Gender:
*
Male
Female
Race:
*
White
African American
American Indian
Hispanic
Other
Marital Status:
*
Single
Married
Divorced
Widowed
Ethnicity:
*
Hispanic or Latino
Not Hispanic or Latino
Employment Status:
*
Full-time
Part-time
Student
Unemployed
Student Status
Full-time
Part-time
Emergency Contact:
Name:
Phone:
(###)
###
####
Relationship:
Pediatrician Info (if a minor)
Pediatrician Name:
Phone Number:
(###)
###
####
Who referred you?
Insurance Information
Insurance Company Name:
Name of person insured:
Social Security Number:
Date of birth:
MM
DD
YYYY
Insurance Company Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Policy Type:
Group Name:
Group Number:
Member Number:
Thank you!
