Forms to Complete
Kindly take a moment to provide me with the following information so that I may maximize the effectiveness and safety of our sessions together. All information provided by you will be kept confidential.
You may fax (1.512.233.5361) or mail the completed forms to me (11506 Oak Knoll Drive, Austin, Texas 78759). Faxing is the most secure way to send me information; only I see your documents. Email is another way to send your forms; my email address is email@example.com
Which forms do I complete?
Health History Intake Form (2 pages) - for all new clients.
Oncology Massage Intake Form (3 pages) - for all people who have had a history of cancer and/or are currently going through cancer treatment now.
Manual Lymph Drainage Breast Massage Consent Form (one page) - for all men and women requesting a lymphatic session.
For all people who have had a history of cancer and/or are currently going through cancer treatment now, please print and complete BOTH forms (health history and oncology massage).
Note: If you are currently in treatment, between treatments or if your last treatment was within one year of the date of our anticipated massage session, I need to have your physician complete an "acknowledgment/special instructions letter." Call or text me at 512.576.1050 for a copy of this form.
For those requesting a lymphatic session, this breast massage consent form will be added to your intake form(s). This is in accordance with the Texas Administrative Code, Title 25, Part 1, Chapter 141, Subchapter B, rule 141.5, Paragraph (h).
You may fax (1.512.233.5361), email (firstname.lastname@example.org) or mail the completed forms to me (11506 Oak Knoll Drive, Austin, Texas 78759).
This two-page form is for all NEW clients (oncology and not-oncology).
This three-page form is for clients living with cancer. For those who are going through treatment, a "Physician Release" form is also needed. Please call me at 512.576.1050 so I can explain further.