Oncology Massage Therapy Intake Form

offered in partnership from Healwell and Life With Cancer

Please correct the errors described below.

Three free massage therapy sessions are available to people affected by cancer who are in active treatment or are in stages of advanced disease. Active treatment is defined as patients currently undergoing chemotherapy, radiation therapy, proton therapy, aromatase inhibitors and immunotherapy.

Client Information

(If different from the client name.)

Medical History

To the best of your ability, please try to include dates and types of treatment.

Emergency Contact Information

Add another emergency contact

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