Welcome to new patient and student registration.
Please download and complete the intake forms. Bring them with you to your first appointment or email them to my office directly.
New Patient Registration – The following three forms should be completed PRIOR to your first appointment.
Orthopaedic Inventories (For back or neck pain patients only)
Ayurvedic Inventories (For Ayurvedic consults only)
- Constitutional Analysis (dosha & guna test)
- Twenty Attributes Self-Test (part of Ayurvedic exam to help you determine what type of yoga is right for you)
- Ayurvedic Daily Routine
Dance Medicine & Women’s Health
- Women’s Health Patient History Intake Form
- Bladder Diary Instructions
- Bladder Diary
- Dancer and Women’s Health Inventory
- Edinburgh Postpartum Depression Inventory
Medical Record Release Form
IMPORTANT INFORMATION TO READ ABOUT REGISTRATION:
- The first three forms should be completed prior to your first visit.
- If you answer “yes” to any of the medical questionnaire on the Patient Intake Form, you may need a doctor’s referral for therapies.
- If you are concerned about health problems and/or your ability to participate in group yoga or Pilates, physical therapy or sports medicine therapies, please contact Ginger directly.
- Patient Privacy Disclosure Statement:
In filling out the patient registration, I understand that CCIM will maintain my privacy to the highest standards and may use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided and any administrative operations related to treatment or payment.