Call/Text: 352-801-1523

2575 Kurt St.

Suite 103

Eustis, FL 32726

©2019 by Impact BodyWorx, LLC.

Therapist License #MA80450

Establishment License #MM35490

Please click the PDF below to download and fill out. You can either email it back to norma@impactbodyworx.com, or bring it with you to your appointment. Filling out this form will help your therapist have a better understanding of any symptoms and contraindications she may need to be aware of so that she can devise a plan of therapy that best suits your needs and optimizes the outcome. See you soon!