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Client Intake Form

Did you know that many patients with SMAS have other pre-existing conditions such as Crohn’s disease, Celiac disease, and other gastrointestinal disorders?

Regardless of your situation, we can offer support as you treat or prevent SMAS. Please take our FREE consultation form and we will be in touch!

New Client Intake Form

General Information

First Name

Last Name

Address

City

State/Province

Zip/Postal

Home Phone

Mobile Phone

Email Address

Date of Birth

Gender

Relationship Status

Occupation

Hours Per Week

Referred By:

Children?

Yes

How Many?

Ages

Your Major Complaint?