New Client Form: Confidential Information.

Please take a moment to fill out the below form. All the information submitted is kept and filed. I do not share any of this information.

Please note the following before submitting your form.

  • I understand that this  massage is not a replacement for medical care and that no diagnosis will be made.
  • I am responsible for paying for any appointment cancellation of less than 24 hours.
  • I understand that Marsha Cook operates independently as a sole proprietor.

By sending this form, I acknowledge the above and agree with them.

NEW CLIENT FORM

YES NO
YES NO
Accident Sprains Fibromyalgia
Neck Pain Seizures Breast Augmentation
Whiplash Abdominal High Blood Pressure
Headaches Mid/Low Back Pain Varicose Veins
Disk Problems Arthritis Bursitis or Gout
Joint Ache Diabetes Nervous Tension
Allergies to Oils Stoke Heart Attack
Cancer Decreased Range of Motion Broken Bones
HIV Contacts/Glasses Surgery
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