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Have an account?

Health History

Client is
Minor (under 18)
Adult (18 and over)

Medical History

Have you ever been in a car accident?
Yes
No
Have you ever had whiplash?
Yes
No
Do you have any allergies or sensitivities?
Yes
No
Are you pregnant?
Yes
No
Choose the areas where you are comfortable being treated
What kind of pressure do you prefer for a massage?
Light
Medium
Firm
Deep Tissue

Medical Records Release

I agree that the medical history given has been completed to the best of my ability and I will inform the practitioner of any changes. This Medical Intake form is valid for one calendar year from the date completed. This information will be kept confidential.  I understand the treatment session could be terminated at any time.

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Please Note: This is a cash-based, private-pay practice. Insurance is not accepted or billed.

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