• Alba Wellness, Inc. Intake Form


    _____________________________________________
    Counseling – Transformation – Empowerment
    433 Kitty Hawk Rd. Suite 219 Universal City, TX 78148
    Phone (210 ) 566-1280 | Toll Free (855) 566-ALBA | Fax (210) 566-1289

  • I hereby authorize Alba Wellness Incorporated and its’ representatives to release my personal health information.

    This information will be released to:

  • I am signing under the following conditions:

    • My judgment is not impaired by emotional duress or any chemicals
    • I may withdraw this authorization in writing at any time
    • If not withdrawn, this authorization expires in (12) twelve months