Fertility Intake and Health History

We are excited to work with you. Please be as thorough and honest as possible when filling out your health history so that you can receive the best possible massage. 

Please contact us with any questions or when you are ready to schedule you massage!

Personal Information
Name *
Address *
Phone *
Emergency Contact *
Emergency Contact
Emergency Contact Phone Number *
Emergency Contact Phone Number
Fertility Information
Menstrual Cycle
Day 1 would be the first day of your period and the day before your period starts is your last day
Massage should not be time between ovulation and the start of menstruation.
Health History For Massage
Do any of the following apply to you: *
The above information is accurate and true to the best of my knowledge. I understand that massage therapists do not diagnose disease, prescribe medications or manipulate bones. I further understand that massage therapy is not a substitute for medical attention or examination. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health. Please type your name to confirm you have read this consent.