Community Clinic Intake & Agreement Form - Dr. Ida Rolf Institute
This form is required to apply for participation in the Community Clinic.

The information you provide helps us assess your needs and provide you with a more personalized experience. Please take your time and answer the questions thoroughly. **We especially need the dates of any injuries or surgeries.** If you don't supply those we will have to call you for clarification and that will delay approval of your application.

You may stop, save your responses, and come back later before submitting this form. BE SURE YOU SAVE BEFORE YOU EXIT!

**Please retain the provided access code to use with your email address, for re-entry. (The access code will also come to you via email.)

If you are filling out this form for the first time, please click the New Submission button on the left .

If you are returning to edit or complete a previous submission, please fill out the email address and access code you set up previously and click Edit Submission.


First time submission




Edit existing submission
(fill out email address and access code to edit form)