• INTAKE FORM

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Examples: Referred by a doctor, referred by friend/colleague/family, advertising (brochures, banner, etc.), by chance/walk in, by employee staff, internet search, returning patient
  • Confidential Health History Form

  • Authorization for Submission & Direct Payment

    Please fill out form ONLY if we bill directly to your insurance company. List can be found in FAQ.
    If "No" or "will submit myself" please skip to the next section
  • Date Format: MM slash DD slash YYYY
  • Please print out your FULL name.
    Thank you kindly for your cooperation with this matter.
  • Consent for Massage Therapy

  • Please input your FULL NAME here!
  • Date Format: MM slash DD slash YYYY