Prior to your appointment - Please fill out this form and email to back me by clicking the Send button below.
  • Date Format: MM slash DD slash YYYY


  • Check the following conditions that apply to you, past and present. Please add your comments to clarify the condition.
  • I understand that a massage/energy Therapist does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand that draping will be used at all times. I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the massage session, and they will end the session. I understand that the massage/energy Therapist may end the session for any inappropriate behavior. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status.
  • By typing your name below constitutes a signature.
  • Date Format: MM slash DD slash YYYY