How did you hear of us*?

If it was a Friend/Colleague, enter their name and e-mail address to get them FREE $35 CMC Massage Dollars for use in the clinic.

Name:

Email:

Have you ever received a professional massage?

Yes (Please see next)
No

If so, when was the last time?

What is your goal for receiving massage:

If reason is other, please explain.

Are there any health conditions that we should be aware of?

Please list any medications and/or supplements that you are taking.

Please indicate your Primary Care Physician

In Case of Emergency, please notify:

Name*:

Phone Number*:

Relationship:

Any other comments, remarks or anything that we should be made aware of prior to your receiving treatment?

Terms & Conditions

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension.  Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions.  I agree to keep the practitioner updated as to any changes in my medical profile and understand there shall be no liability on the practitioner's part should I fail to do so.

Our time together is precious & I agree to cancel 24 hours in advance. If I miss an appointment, I agree to pay the full price of the appointment fee.

I Accept These Conditions.

For a complete list of our Terms & Conditions, please click here.