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janethale@pacephysio.com

514-792-4136

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Intake Form

Child's First & Last name

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Day

Year

Address & Postal Code

Your Name, Phone Number & Email

Child's Doctor & Address

Your current concerns, issues first noticed & your goals

Other team members involved

Pregnancy & Child's Birth History (difficulty during pregnancy, type of delivery, delivery time, prematurity, head preference)

Health & Medical Issues, Medications

Milestones (if applicable)

janethale@pacephysio.com

514-792-4136

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