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New Client Intake Form

Once you've booked your session, save some time by completing an intake form prior to arriving.
This will let us know how we can best serve you.
Please know, all information provided will be kept confidential.

How would you rate your general health?
Are you pregnant?
What therapeutic service(s) have you had?
Have you been in or had any major accidents or surgeries
Please indicate if you have or have had a history of any of the following

It is my choice to receive Manual Lymphatic Drainage, Massage Therapy (with or without CBD), and, or Cupping Therapy (Therapies). I am aware of the benefits and risks of Therapies and give my consent for Therapies. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that Therapies are not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

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If I experience any pain or discomfort during a session, I will immediately inform the therapist so the treatment may be adjusted to my level of comfort.

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I understand that I may terminate a session at any time if I feel uncomfortable with the course of treatment. The therapist also reserves the right to end the session in the case of any inappropriate behavior.

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I understand that my personal health information will be collected. I understand and consent that the medical information I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

Thank you for entrusting us with your care.

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