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Client Intake Form

Client Information

Age / 年龄 *

Occupation / 职业 *

Medical / History Data

Do you have any of the following conditions / 您是否有以下情况?
Are you wearing any eye contact lenses / 您是否有佩戴隐形眼镜?
Are you pregnant, breastfeed, or nursing / 您是否怀孕或哺乳? (Female/女性)


  • I confirm that all information given in this form is true, complete, and accurate. 

  • I released this organization for any responsibility in case of accident, illness, or injury. 

  • I acknowledge that no assurance was offered about the outcome.

Thank You!
Your submission has been received.

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