Appointments/ Contact us

To schedule an appointment, please look at our availability and then fill out the below form. Alternatively, you may call 206-226-8953. If we are unavailable or with another client, please leave a message.

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Name:*
Phone:*
Email:
Address:
Dates and times you are interested in receiving a massage:
Are you planning to use your insurance for the massage? No
Yes
Have you given us your insurance information previously? No
Yes
Other comments or questions:


Insurance Information:

Your date of birth:
Name of primary insurance holder (your name if you):
Date of birth of primary insurance holder (your name if you):
Type of insurance:
Specific medical insurance provider:
Claim/Case/Subscriber number:
(If applicable) Group number:
Do you have a prescription or referral for Massage Therapy? No
Yes


Prescription/Referral Information:

Details of the Diagnosis (frequency, duration of sessions, target areas):
Name of doctor:
Type of doctor:
Doctor's phone:
Doctor's fax (if have):