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For outcall services: Please make sure your location is on the 1st floor, or have elevator access. Thank you for understanding.

Client Information

First Name

Address

Email Address

Are you pregnant?

No

Yes

Have you been hospitalized in the last 12 months?

No

Yes

Last Name

Date of Birth

Phone

Are you taking any medications?

No

Yes

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Please read and check each box below:

Yes, I am at least 21 years old.

I understand that this massage is not a replacement for medical care and that no diagnosis will be made.

I am responsible for paying for any cancellation if less than 24 hours.

I understand that any illicit or sexually suggestive comments or actions made by me will result in the immediate termination of my session and I am responsible for full payment.

I declare that the info I’ve provided is accurate & complete.

Initials

Today's Date

Thanks! See you soon!

TEXT TO BOOK: 512-897-2465

EMAIL: higherhealingATX@gmail.com