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.

This program is very popular. We will schedule your appointment as soon as possible, but for some locations appointments book out weeks in advance.

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

Please do not list yourself as an emergency contact. In the unlikely event of an emergency it is important that we know who to call.

Add another emergency contact

Thank you for completing this form. A Healwell staff member will contact you as soon as possible.

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