Relax & Be Well

Therapeutic Massage

Has child ever received professional massage?*
Has child tried any other treatments for concerns listed above?*
Birth History*
Was child born prematurely?*
Were there any postpartum complications with the child?*
Is your child currently under the care of a primary health provider?*
Has the child been diagnosed or treated for any of the following disorders/conditions? Please check ALL that apply.*
Has the child had any accidents, injuries or surgeries in the past 6 months?*
Does the child have any allergies/sensitivities to oils, lotions or scents?*
Please list your child's communication style *
Does your child exercise or participate in sports? *
Wavier of Liability and Consent to have Massage*
Cancellation Policy*
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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