Consult Form — Harris Manual Therapy

Harris Manual Therapy

Clinic@HarrisManualTherapy.com

818.454.1136

5818 Morella Avenue, Valley Village, CA 91607

Click here for downloadable PDF Intake Form B
Please complete prior to your first session and email to clinic@harrismanualtherapy.com
Click here for downloadable PDF Intake Form C
Please complete prior to your first session and email to clinic@harrismanualtherapy.com
Prepare for your first session with this information sheet

INTAKE FORM A

Date of First Session

First Name *
Last Name *

Cell Phone *

Alternate Phone

Email *

Date of Birth *

Occupation

Employer

Referred by

Spouse or Significant Other's Name

Children's Names & Ages

Name of Emergency Contact *

Emergency Contact's Phone *

The more information you can provide on these forms, the better equipped Craig will be to help you through this challenging time

Clinic location

5818 Morella Avenue
Los Angeles, CA

Hours
Monday–Friday
10am–6pm

Phone
818.454.1136