Healwell Massage Therapy Intake Form

for patients and caregivers in partnership with Life with Cancer

Please correct the errors described below.

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

She/her, He/him, They/them, etc.
(If different than the client's name)

Medical History

Payment Information

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

Emergency Contact Information

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

Add another emergency contact

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