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Tierza Clerc (Utopian Hands Massage Therapy)

Personal Information
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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


  • 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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