• 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.
  • 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!