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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 Information
Referring Healthcare Provider

Primary Insurance Provider

Attorney

  • By checking the Consent Box, I am am agreeing to receive massage therapy for therapeutic purposes. I can revoke this at any time.
  • 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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