Massage Intake Form

We incorporate state-of-the-art equipment in our analysis of your healthcare needs. We individualize your care program to fit your specific lifestyle.

If having high energy, reducing the negative effects of stress and enjoying life to its fullest are important to you, then please contact our office today so we can help you!

Address
MM slash DD slash YYYY
Permission to consult with health care provider
Physician's Prescription note:

Please check the appropriate box for any of the following conditions you currently have. Please underline any of the following conditions that you have had in the past.

Respiratory
Musculoskeletal
Digestive
Circulatory
Nervous System
Skin
Genito-urinary
Other

Message History / Treatment Information

Have you ever received a professional massage?