Be Well LifeStyle Centers

Massage - Initial Intake - General Consent

📌 Please complete all sections of this form.

IMPORTANT:

  • We use your answers to build your personalized care plan.
  • Missing information slows down our ability to assist you.
  • This may delay or limit your treatment options.
  • Take your time, be thorough, and don't leave anything blank unless it doesn't apply.
  • (Yes, we read every word.)
  • Your results will thank you.
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Section 1: Basic Information

👤 Please enter your legal name — exactly as it appears on your insurance & photo ID. This is how your visits and billing are matched, so please don't use a nickname here.
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Insurance Info

Massage Experience

Health Conditions

Do you experience any of the following? (Check all that apply)

Massage Preferences

Are you currently experiencing pain? If yes, please indicate areas:

Consent and Agreement

Signature

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