New_Patient

If you are coming back to finish your paperwork, please use your Name and Date of Birth (DOB), then skip to the part you need to finish, we'll put the pages together at the office. Pressing "SUBMIT" takes you back to our Fast Home Page. Or, you may get out now (if you promise to come back to finish the paperwork):

Minors must be accompanied by a Parent or Guardian. The Parent or Guardian must countersign all forms at the office and be present in the room during the Massage.

Medications List - Both OTC (over-the-counter) and Prescription
Please list the Med Name, Strength, and When you take it: Skip a line between Meds

Please indicate and conditions you have experienced in the last 2 years.
List current conditions at the top of this section. "A" and "B" just allows us to have two columns.

Images not created by us are: Pixabay Free for Commercial Use

Did you Know?

Beth Ann Borecky is a Medical Massage Therapist

has been in practice for almost 25 years. And has been responsible for over 100 people learning to be Massage Therapists!

Please fill out: (Please note: The red * must be filled in)

Medical Information Section