Oncology Massage Intake Form
This intake form is for those seeking massage therapy who are currently undergoing or have any history of a diagnosis of cancer and cancer treatment (except breast cancer). If you are seeking massage for general therapeutic purposes, manual lymphatic drainage therapy, or have a history or diagnosis of breast cancer please complete the appropriate intake form at www.hartlmt.com.
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
Never submit passwords through Google Forms.
This form was created inside of Amy Hartl, Licensed Massage Therapist. Report Abuse - Terms of Service