Dr. Nicole Sirota

Home

Curriculum Vitae

Corporate Wellness

FAQ

Fitness

Contact Nicole

To schedule an
appointment, call
949-328-9944
or email

Available Orange County Locations:

Laguna Hills

Laguna Beach

Laguna Niguel

Irvine

Newport Beach

Lake Forest

Mission Viejo

Aliso Viejo

Dana Point

Huntington Beach

Rancho Santa Margarita

Foothill Ranch

Home visits

Health fairs and corporate events

Private events

Spa parties

Additional Modalities:

Myofascial Release

Muscle Energy

Acupressure Points

Energy Healing, Visualization and Breathwork

Patient Information Form

Name

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Date of birth

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Appointment Date

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Gender

MaleFemale

Address

City

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ZIP Code

Phone number

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E-mail address

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Occupation

Activities

Reason for visit

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Medical history

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Do you have
conditions you are
under doctor's care
for?

Please check if
if you have

Asthma	Diabetes	High blood pressure
Allergies	Heart disease	Peripheral vascular disease
Cancer	Lung disease	Urinary incontinence
Pregnancy	Menstrual cramps	Varicose veins
Anemia	Insomnia	Depression
Headaches (tension or migraine)
Acute injuries (muscular strains, sprains, etc.)

Current medications

Other medical
treatments

Are there any areas
you would like avoided
or are sensitive to
touch?

Questions

I have reviewed and answered the above questions. To my knowledge the answers are true and will be discussed with Dr. Nicole Sirota prior to treatment. I give Dr. Sirota consent to treat me and at any time I feel uncomfortable I may ask to stop the session. Payment for the treatment is due upon completion of the session.