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Get Pediatric Massage Intake Form

Pediatric Cli ent Intake Form Child s Name Birthdate Age Parent s Name s Home Phone Work Phone Cell Phone Street City State Zip Parent Occupation/Employer Please mark your goals for your child s Pediatric Massage Program Provide Comfort Promote relaxation Reduce stress Reduce pain Ease Depression Decrease anxiety Reduce muscle hyper tonicity Improve muscle tone decrease hypo tonicity Improve gastrointestinal functioning Improve joint mobility / r.

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