Massage Intake Form

Massage Intake Form
Personal Information
Do you have any of the following
Have you ever had/do you have any of the following
Complaint Details
Is this condition
Physician Information
Have you seen a physician for this?
May we contact your physician?
Are you now under medical/therapeutic treatment?
INITIAL FOR THE FOLLOWING: Missed appointments are subject to a $25.00 fee. A 24-hour notice must be given to cancel. INITIAL
Agreement and Signature

Thank you for taking the time to fill out this form.

Location

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Office Hours

Our Regular Schedule

Providence Office

Monday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Tuesday:

Closed

Wednesday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Thursday:

Closed

Friday:

9:00 am-1:00 pm

2:00 pm-4:00 pm

Saturday:

Closed

Sunday:

Closed

Massage Therapy Hours

Monday:

8:30 am-5:15 pm

Tuesday:

11:00 am-4:30 pm

Wednesday:

8:30 am-5:15 pm

Thursday:

9:00 am-4:00 pm

Friday:

8:30 am-3:45 pm

Saturday:

Closed

Sunday:

Closed

Testimonial

  • "I have benefited tremendously from the chiropractic care I received from Dr. Wade."
    - Jeffrey L. Providence, UT