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Massage Therapy Intake Form

Date
Birthday

Health History

Have you had a professional massage before?

Add your text

Are you taking any medications? If so, please list.

Have you had any major surgeries? If yes, please list.

Do you have any allergies? If so, please list.

Are you pregnant?

Do you have any of the following conditions?

Multi choice

Reason for massage therapy visit?

What type of pressure do you prefer?

Multi choice

By submitting this form, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

BY APPOINTMENT ONLY

MONDAY-FRIDAY

7.00AM-8.00PM

​SATURDAY

​7.00AM-1.00PM

 

ADDRESS

2245 S. Reynolds Rd.
Toledo, OH 43614
embodywellness@live.com

Direct Line: 419-460-9838

Tel: 419-966-0959 (massage therapy)

Tel: 419-315-5124 (personal training)
 

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