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Tierza Clerc (Utopian Hands Massage Therapy)


Personal Information
Male Female Other

Emergency Contact

Select the Intake form that best represents the type of massage care your are currently seeking.

Wellness Intake
Treatment Intake
Billing and Insurance Information
Referring Healthcare Provider

Primary Insurance Provider
If there is no plan#/group#, put the name of the insurance company in this section

Attorney

  • I give my consent to receive massage therapy
    By checking the Consent Box, I am am agreeing to receive massage therapy for therapeutic purposes. I can revoke this at any time.
  • I give my consent to receive treatment or to vary the draping protocol in these additional areas (see text box below) for therapeutic purposes
    I am checking this box after the massage therapist and I have discussed the purpose, draping, and treatment plan involved.
    I can revoke this consent anytime.


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