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 also understand and agree that receiving a Quantum Health session from Gayathri does not replace current or ongoing medical protocols or your physician’s advice.
  • Please email a recent photograph (not older than 3 months) if live internet access is not available. 
  • Complete Payment using PayPal or pay E-mailed Invoice within 24-hours of your appointment.
  • You may schedule your appointment online using the Schedule Now Button. Please allow 24 – 48 hours for a response.