Healwell Massage Therapy Intake Form

Scheduling your appointment

When you have completed this form a Healwell representative will contact you directly to schedule your first session.

Healwell is pleased to partner with Life with Cancer to provide discounted massage therapy ($70/session) to patients and caregivers. Please complete this form and we will contact you to schedule an appointment as soon as possible.

Client Information

First name

Last name

Preferred name

Date of birth

What are your pronouns?

She/her, He/him, They/them, etc.

Email address

Phone number

Contact Name

(If different than the client's name)

Preferred method of contact

Phone Text Email

What is your occupation?

Is there anything you hope to achieve through massage therapy?

Medical History

Have you ever been treated for cancer?

Yes No

If yes, please describe the cancer and your treatment(s).

Please list any medications you are taking and any side effects you experience.

Are you pregnant?

Yes No

If yes, when is your due date?

Do you have any allergies or sensitivities?

Yes No

If yes, please describe.

Is there anything else you'd like your massage therapist to know?

Payment Information

A credit card is required to reserve your appointment. We will not charge your card until AFTER your session.

Your name as it appears on the card.

Credit card number

Expiration date

Security code

Billing address

City

State

Zip code

Emergency Contact Information

*Please do NOT use your own contact information for your emergency contact.

Add another emergency contact

Would you like to receive our monthly newsletter (via email)?

Yes, please No, thank you

Your information will be encrypted.

Healwell

Healwell is raising the bar for massage therapy's role in the future of how humans will care for humans. Exceptional, meaningfully-integrated massage therapy provided by uncommonly compassionate and skilled massage therapists is a rare thing in today's hospitals and clinics. We're changing that... one therapist, one clinician, one patient at a time.