Therapeutic Massage Intake Form
This intake form is for general therapeutic massage purposes. If you are seeking Manual Lymphatic Drainage Therapy or have ever received a diagnosis or treatment for cancer please complete the appropriate intake form at
Email address *
Your Information
Please share your basic contact information and contact preferences so that I know the best way to stay in touch.
Name *
Your answer
Date of Birth *
Address *
Your answer
Telephone Number *
Your answer
Preferred Contact Method *
Would you like to receive a weekly email offering open sessions when available? *
Would you like to receive an occasional newsletter with information and resources? *
How did you hear about me?
If you were referred to me are you willing to let me thank the person? If so please share their name.
Your answer
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