Intake Form

Please fill out this form within 24 hours of your appointment.

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Have you received buccal massage or manual lymphatic drainage before? If so, when?

What are your goals for this session?

Prior surgeries:

Cosmetic treatments or filler:

Are you currently pregnant?

Yes

No

Do you have any allergies? Please list.

Please list all medications.

Health History

Please review this list and select conditions that have affected your health either recently or in the past.

Abdominal Pain

Anxiety

Arthritis

Asthma

Auto Accident

Autoimmune Disorder

Back Pain

Blood Clots

Broken Bones

Bruises Easily

Cancer

Carpal Tunnel

Celiac Disease

Cold Sores

COPD

Congestive Heart Failure

Constipation

Crohn's Disease/Ulcerative Colitis

Depression

Diabetes

Diverticulitis/Diverticulosis

Dizziness

Eczema

Edema

Emphysema

Endometriosis

Epilepsy

Eye Strain/Pain

Fainting

Fibromyalgia

Gas/Bloating

Gout

Headaches

Hearing Issues

Heart Attack

Herniated Disc

Insomnia

Irritable Bowel Syndrome

Jaw Pain

Lyme Disease

Lymph Nodes - Enlarged

Lymph Nodes - Removed

Migraines

Mold Exposure

Multiple Sclerosis

Numbness/Tingling

Neuropathy

Osteopenia

Osteoporosis

POTS

Psoriasis

Rheumatoid Arthritis

Scoliosis

Sinus Issues

Surgical Implants

Please provide more information about the above, if necessary.

How to find us?

27 Round Hill Rd, Kinnelon, New Jersey 07405

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FAQs

Buccal massage is specialized massage technique that targets deep facial muscles inside the mouth and along the jawline to relieve tension, improve circulation, and sculpt the face. This method helps release tightness caused by stress or jaw clenching, promoting relaxation and reducing symptoms of temporomandibular joint (TMJ) disorders. By increasing blood flow and stimulating lymphatic drainage, buccal massage can also enhance skin radiance and reduce puffiness. Over time, it strengthens facial muscles, providing a natural lift and contour. Ideal for those seeking both aesthetic and therapeutic benefits, this technique offers a holistic approach to facial health and wellness.
This is a paragraph where you can include any information you’d like. It’s an opportunity to tell a story about the company.
This is a paragraph where you can include any information you’d like. It’s an opportunity to tell a story about the company.
This is a paragraph where you can include any information you’d like. It’s an opportunity to tell a story about the company.
This is a paragraph where you can include any information you’d like. It’s an opportunity to tell a story about the company.
This is a paragraph where you can include any information you’d like. It’s an opportunity to tell a story about the company.
This is a paragraph where you can include any information you’d like. It’s an opportunity to tell a story about the company.
This is a paragraph where you can include any information you’d like. It’s an opportunity to tell a story about the company.

More ways to reach Firm & Flourish.

As a small business, it is easiest to reach us by text message. We will get back to you as soon as possible.