Intake FormPlease fill out before your first appointment. We can't wait to hear from you! Name * First Name Last Name Email * Phone * (###) ### #### Emergency Contact (name & phone number) Have you had a massage before? Yes No What level of pressure do you prefer? Light Medium Firm Deep Glute work (Swedish only) Skin to skin Through the sheet None Please indicate if any of the following apply Areas of swelling Back/neck surgery Blood clots Cancer Fibromyalgia Headaches Heart Condition Hypertension Migraines Multiple Sclerosis Neuropathy Osteoporosis Sciatica Seizures Tendinitis TMJ disorder Vertigo/dizziness If yes to any conditions above or any others not listed, please describe. How did you hear about us? Friend/Family Social Media Internet Search Chiropractor Referral Referral Site Other Cancelation Policy * 50% Payment is required for cancelling within 24 hours. 100% Payment is required for a no show. I understand and agree Session Termination Policy * Inappropriate behavior of any kind will not be tolerated. In the event that misconduct should occur, the session will be ended immediately and full payment for the service will be required. I understand and agree Thank you!
