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Are you under a Doctor’s care?
Are there any Chronic Problems? WHAT?
Do you have any heart problems? WHAT?
Do you have Diabetes? What Type? How Long?
Do you have Kidney or Bladder problems? What?
Do you have Chronic Pain? Where? Constant/Intermittent/How long have you Had this?
Please describe your chief Complaint(s), at this time:
Please relay any information that may interfere with receiving massage: (active, Cancer, broken bone, pregnancy, etc..)
I will be paying for my Massage(s) by
CashCheckCredit CardGift Certificate
Your appointment time(s) are reserved for you. 24/72 hours notice is required to cancel an appointment. If unable to fill the cancelled/missed or frequently reschedule appointment, you may be required to pay for appointments. _____initials No Refunds on Gift Certificates or Pre-paid packages.
I swear or affirm all information given is true or correct to the best of my knowledge and understand the appointment policy.