Do you see a chiropractor?
Emergency Contact & Phone #
List all allergies
Do you have any bone/structrual issues?
Please let us know if you are....
Have high blood pressure
Have a heart condition
Who should we thank for this referral?
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What medicines do you routinely take?
Please read and check the following:
I understand that this massage in not a replacement for medical care and that no diagnosis will be made
How often to you exercise a week?
Massage Intake Form
List all surgeries within the past 4 years
Have you had a massage before?
Thank you for contacting us! If needed, you will hear back within 48-72 hours.
Please read and check the following
I am responsibe for paying a $50 fee for any appointment cancellation of less then 24 hours
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