New Client Health Intake Form

Client Instructions

Complete all fields accurately and provide as much details on your medical history where indicated.

  • By submitting this form, you are giving express consent to receive a Quantum Health Session.
  • You understand and agree that a Quantum Health session does not replace current medical treatments or physician’s advice. 
  • Complete Payment using PayPal or Credit Card within 24-hours of your appointment. You may also mail a check in at least 1 week before your session.
  • Schedule your appointment online using the Schedule Now Button.
  • Please allow 24 – 48 hours for a response.