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New Client Intake Form

New Client Intake Form

Welcome to our online Client Intake Form

This information will be sent directly to our clinic and will help us to better serve your healthcare needs. All your information is kept discreetly and securely.

Please fill out this form, and press the SUBMIT button at the end.

  • Your email will NOT be shared with any third parties.
  • Please include any activities you are involved in that may further our understanding of your needs.
    I understand that massage is not a replacement for medical care and that no medical diagnosis will be made. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all known medical conditions and will keep the therapist updated as to any changes in my medical condition going forward. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or manipulation, draping or environment may be adjusted to my level of comfort.
    Your privacy is important to us. We will only use you email for appointments, some promotion, and news about ACTIVE SOMA. We will not give your details to anyone. Any news or promotional emails will provide the option to subscribe at the bottom.
    I agree to give 24 hours advance notice of scheduled session, or to assume responsibility for payment of the full fee.

Pro Active 5 or 10 Session Packages