MASSAGE INTAKE FORM | Massage By Cheri

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Massage Therapy by Cheri

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Mind-Body Wellness Nervous System Support Relaxation and Recovery Holistic Stress Support Intentional Touch

MASSAGE INTAKE FORM

Please fill out the following form prior to your first appointment.

First Name

Last Name

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Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

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I declare that the info I’ve provided is accurate & complete

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