Tam Tam's Healing Hands Massage

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Tam Tam's Healing Hands Massage

First name

Last name

Email

Phone

Birthday

Address

Company name

Position

Preferred Pronoun

Age

Primary Care Physician

Emergency Contact & Phone Number

How did you hear about us?

Are you taking any medications?

Yes

No

If yes, please list name and use

Are you currently pregnant?

Yes

No

If yes, how far along?

Do you suffer from chronic pain? If yes, please explain

Please indicate any of the following that apply to you:

Cancer

Headaches/ Migraines

Arthritis

Diabetes

Joint Replacement

High/ Low Blood Pressure

Neuropathy

Fibromyalgia

Stroke

Heart Attack

Kidney Disease

Blood Clots

Numbness

Sprains or Strains

Spinal Problems

Trouble Sleeping

Anxiety

Depression

Orthopedic Surgery

Allergies or Sensitivities

None of the Above

Please explain any conditions that you selected above.

What Pressure do you Prefer?

Light

Medium

Deep

What are your goals for treatment this session?

By signing below, I agree that all of the information above is true.

I agree to use electronic records and signatures.

Signature

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