Oncology Form

Relax & Be Well, LLC

Therapeutic Massage and Wellness Coaching

About
Contact
Health Intake Form
Pregnancy Form
Oncology Form
Pediatric Form (0-17)
COVID-19 (Coronavirus) Liability Release Form

About
Contact
Health Intake Form
Pregnancy Form
Oncology Form
Pediatric Form (0-17)
COVID-19 (Coronavirus) Liability Release Form

Name*

Address*

Phone*

Birthdate*

Emergency Contact Name & Number*

Oncologist Name, Clinic Name & Phone Number*

Referred By

When were you first diagnosed with cancer?*

What type of cancer do/did you have?*

Where is/was your cancer located?*

Are you currently being treated?*

YesNo

If yes, when was your last treatment?

What treatments have you undergone and when?*

Please list any medications you are currently taking*

Did your treatment include any removal or radiation of lymph nodes?*

YesNo

If yes, please describe the location and number of nodes affected

If you received radiation therapy, please describe the location

Do you have any site restrictions due to: incisions, open wounds, drains, dressings, skin sensitivities, rash/skin conditions, IV, port, ostomy, catheter or other device?*

YesNo

If yes, please describe

Do you have any pressure restrictions due to (check ALL that apply):*

history or risk of lymphedemalow platelet countanticoagulantsbone or spine metastasissteroid medicationfragile/sensitive skinfragile veinsfatiguearea of pain or burningrecent surgeryinfection or feverNONE APPLY

Do you have any position restrictions due to (check ALL that apply):*

incisionmedicationostomytumor sitedifficulty breathingtender skinmedical devicesswelling or risk of swellingdiscomfortNONE APPLY

How is your energy level?*

Are/did you experience peripheral neuropathy?*

YesNo

If yes, please describe

Any other information the massage therapist should know that is not included above?*

Waiver of Liability and Consent to have Massage*

I agree to submitting intake forms online and waive all claims.I agree to hold harmless Relax & Be Well, LLC, of all claims, including Andree Strauss, her spouse, her heirs, her property and associations.I understand that my information will not be shared with anyone outside of Relax & Be Well, LLC without my written consent.I understand that if I have a specific medical condition or specific symptoms, massage may be contraindicated. A referral from my primary care provider may then be required prior to my massage session. If I experience any pain or discomfort during my massage, I will inform the practitioner immediately.I understand that the massage therapist cannot diagnose any medical conditions, but they can recommend seeing a medical doctor or medical specialist with any concerns.I have answered the above information to the best of my knowledge and will let the practitioner know if anything changes with my health history.

Cancellation Policy*

I understand that I will be charged 50% of my scheduled service fee if I cancel my appointment less than 24 hours before my scheduled time, with the exception of illness, emergency or inclement weather.I understand I will NOT be charged if I need to cancel within 24 hours due to COVID-19 symptoms in myself or another member of my household.

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Thank you for submitting intake form. See you at your first appointment. If you need to schedule your first appointment Click the link below https://squareup.com/appointments/buyer/business/YHWCNL/relax-be-well-therapeutic-massage

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