Healing Services Intake Form Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Have you ever had a bodywork/massage session before? Yes No Do you have any allergies? Are you currently taking any medications? Are you pregnant or nursing? (female only) Ninguno Yes No Do you have any current injuries? Current medical conditions like Asthma, Diabetes, Heart Problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc? Do you have a particular area of concern? Location of painful areas (if applicable) Thank You for Completing the Intake Form We are honored that you’ve chosen Body Wisdom Sanctuary for your healing journey.Your information will help us create a personalized experience tailored to your unique needs. In the meantime, if you have any immediate inquiries, please don't hesitate to reach out to us at bodywisdomsanctuary@gmail.comWe look forward to supporting you on your path to wellness!Warm regards,Siewli Stark