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Health History Form
Name:
Phone #:
Address:
Occupation:
Date of Birth:
Have you received massage therapy before?
Did a health care practitioner refer you for massage therapy?
Please indicate conditions you are experiencing or have experienced:
Other Conditions
Women
Direct Billing?
Upload Image of Extended Health Care Benefits*
Your content has been submitted
Information Collection Notice:
This intake form is used to determine any contraindications, and prepare for our initial contact with you. The information collected will be stored in your confidential client record and will only be accessible by your health care practitioner and those you have given written authorization to.
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