Enrollment Form

All information and videos provided will be kept confidential. We will not disclose your personal information to a third party without your consent.

Name*

Age*

Gender*
MaleFemale

Profession*

City/Country*

Phone Number*

Email Address*

Symptoms and Medical History

Instrument*

The Main Area of Concern: (multiple-choice)*
Hand/ ArmFoot/ LegEmbouchureVocal CordOthers

Please briefly describe your symptoms, how long have you had this condition, and which side of the body (left and right) is affected.*

Have you ever been to the hospital for a doctor's diagnosis?*
YesNo

What have you done for this condition? (multiple-choice)*
BotoxMedicationPhysical TherapyAcupunctureSomatic TechniquesOthers

Do you have any chronic diseases?

Comment

Applicable Time for Sessions (multiple-choice)*
WeekdaysWeekdays eveningWeekend

Please upload videos which you demonstrate your symptoms.*

Thank you for filling out the form. Dr. Monica Chen will review your documents and let you know if you are accepted for the service.