How to submit your health form

Option 1: Download and fill out the printable PDF form

Option 2: Fill out the online form below


Option 1: Printable PDF

Save the PDF to your computer first, then open it with a PDF reader like Adobe Reader or Apple Preview, fill it out, save it, and email it to Or you can print it out, fill it out with a pen, and bring it with you to your first appointment.

Do not fill out the PDF form in your web browser because it won’t save your responses.

Raya Wellness Health Evaluation Intake Form — 623KB (PDF)

Adobe Reader may be required to open the health form.
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Option 2: Online Form

If you prefer, you can fill out the Google form here.

If you prefer, you can fill out the embedded Google form below.