Breast Cancer Massage Intake Form
This intake form is for the purpose of those seeking massage therapy currently undergoing or with any history, diagnosis, and treatment of breast cancer. For any other type of cancer treatment, general therapeutic massage, or manual lymphatic drainage therapy, 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 general massage and health and wellness information and resources? *
Would you like to receive information and resources related to women's issues after breast cancer such as sexual health, body image, lymphedema prevention and education, etc.? *
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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