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Spa Relaxation Session

Patient Information

Please review the document below, download it, complete all required sections, and return it via email to GingkoTherapy@gmail.com.

To be completed by patient, responsible party/legal guardian.

Patient First name

Patient Last name

Date of Birth

Month

Day

Year

Name of Parent/Guardian

Relationship to the Patient

Patient Contact Number/s (mobile, home, business)

Home Address

In Case of Emergency; name and phone number

Patient E-mail Address

How did you hear about us?

Current Occupation

Please describe the reason or problem for which you are seeking our services

+1 (773) 780 5113

GingkoTherapy@gmail.com

Whether you're seeking relief from chronic pain, recovering from injury, or looking to optimize your body's function, we're here to help.

© 2025 by Gingko Therapeutics, LLC. All Rights Reserved.

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