Available by appointment Tues-Fri, 9a-5p. Feel free to contact me with any questions, or to schedule your appointment. For evenings and weekends, please contact officemate Desiree Sharp LMT at 503-547-8400, lic#10589

Intake Form

Before your first visit, please either click here to print and fill out an intake form, and remember to bring it with you to your appointment or . . . just fill out the online intake form below. Looking forward to our session!

Name

Date

Address

Phone number(s)

Birthdate

Occupation

Email address

Who referred you to this office?

Have you ever had a massage before?
No Yes
When:

What results would you like to see from your sessions?

Are there any areas of your body you would like to focus on or prefer be avoided?

Please include the names of any healthcare professionals you are currently seeing.

Do I have permission to contact them concerning your current condition, if I feel that it is necessary for your safety?
Yes No Only with my express consent, on a per-incident basis.

Are you currently taking any medications/supplements/herbs/homeopathic remedies?
No Yes
Which?

Have you ever had any form of cancer? Please include type, dates, and current status.

Have you ever had any surgeries or major injuries? Include approximate date and current status.

Please indicate if you currently or in the recent past have had any of the following:

diabetes
asthma
communicable disease
difficulty sleeping

high/low blood pressure
allergies
skin conditions
headaches/migraines

Would you like a reminder of your appointment?
(Not guaranteed, client responsible for keeping appointment regardless)
Email reminder Day-before phone call No, thanks

All massage received will be therapeutic wellness massage, to promote relaxation and relieve discomfort caused by tension. By signing I declare that, to the best of my knowledge, the above information is accurate and truthful. According to informed consent, I acknowledge that I am aware of the minor potential for soreness, bruising, or headaches in the days following a therapeutic massage. I also acknowledge that I am aware that any massage received will be NON-sexual in nature. If, at any time, either client or therapist feels uncomfortable with the situation, the session may be terminated immediately.