Massage Intake Form
Welcome to Pohala Clinic! In order to provide you with the best possible experience and to customize your service to your needs, please complete this form. Your information will help us assure your safety and satisfaction.
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Email *
What is your legal name? *
What name do you prefer to use? *
What is your date of birth? *
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Please list your address: *
Please list your phone number: *
Were you referred by anyone? If so please list their name: *
Please list your emergency contact name, and their relation to you: *
Please list your emergency contact phone number: *
Please list any current medications & the conditions they are treating: *
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