Book a Bodywork/Massage session with me

Name *

First Name

Last Name

Preferred Pronouns

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

####

Do you have or have you had any of the following:

cancer

heart or cardiovascular issues

blood clotting issues

high blood pressure

depression

anxiety

any autoimmune issues

nervous system issues

kidney or liver disease

strokes

arthritis

diabetes

major surgeries

broken bones, sprains or dislocations of joints

eye issues

ear issues

COVID-19

Lyme disease or another tick-borne illness or infection

Do you wear:

contacts

hearing aid

a wig or hair piece

dentures or false teeth

any prosthetic device

Are you currently pregnant?

Yes

No

If you are pregnant, when is your expected due date?

MM

DD

YYYY

Do you see a dermatologist and/or get regular skin checks? *

Yes

No

Are you content with your current level of activity?

Yes

No

Have you received a professional massage before? *

Yes

No

Are you a survivor of any kind of abuse?

Yes

No