Massage Intake Form

Massage Intake Form 

Have you in the past had any of the following conditions (mark all that apply)
Do you currently experience any of the following (Mark all that apply)
Are you currently receiving care from a M.D, D.C., N.M.D., or D.O.

I understand that Massage Therapy given here is for the purpose of reducing stress, relieving muscular tension, spasms, increasing range of motion, circulation and energy flow.

I also understand that the Massage Therapist does not diagnose illness, medical conditions, disease or any type of physical or mental disorder. It is recommended that I be evaluated by a Doctor for any physical ailment that I might have. The Massage Therapist does not prescribe pharmaceuticals, medical treatment or spinal manipulations. It is understood by me that Massage Therapy is not a substitute for medical or chiropractic treatment, but to assist in a recovery process.

A Massage Therapist must be aware of existing physical conditions, therefore I have stated all my known medical conditions and will notify the Massage Therapist of any changes that occur in my physical health. If I experience any pain or discomfort during the session I agree to immediately notify the Massage Therapist so that a comfort level can be adjusted.

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1. Please arrive to your session with clean skin and notify the Massage Therapist of any broken skin or lesions due to the health risks involved with contact.

2. As a courtesy to others those with allergies and sensitivities please do not wear any perfume/cologne to your session. It is greatly appreciated!

3. 24-hour cancellation notification is required to avoid a $35 missed appointment fee.

Thank you for taking the time to fill out this form.

Cann Chiropractic Center

Address

3076 East Chandler Heights Rd., Se. 107,
Gilbert, AZ 85298

Monday  

9:00 am - 6:00 pm

Tuesday  

9:00 am - 3:00 pm

Wednesday  

9:00 am - 6:00 pm

Thursday  

8:30 am - 4:00 pm

Friday  

8:30 am - 4:00 pm

Saturday  

Closed

Sunday  

Closed

We look forward to hearing from you

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Please do not submit any Protected Health Information (PHI).