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GYS Intake Form
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First Name *
Last Name *
Date of Birth
MM
/
DD
/
YYYY
Referred By
Email Address *
Phone Number(s) *
Street Address *
City *
State *
Zip Code *
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone #
Physician Name
Physician Phone #
Any allergies to oil fragrances?
Date of Initial Visit
MM
/
DD
/
YYYY
How would you rate your general health?
Clear selection
Have you had a professional massage before?
Clear selection
List current medications and conditions you are treating
List any major surgeries or accidents (including dates)
Please tell us about allergies or hypersensitivities
Reason for initial visit
 Have you had a fever or felt feverish? *
Do you have a cough? *
 Have you knowingly been in contact with anyone confirmed positive for COVID-19? *
 Have you knowingly been in contact with anyone confirmed positive for COVID-19? *
Have you traveled in the past 14 days? *
Head / Neck
Respiratory
Cardiovascular
Nervous System
Skin & Infections
Musculoskeletal System
Reproductive
Other Conditions
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examinations, or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.                                                                                ___________________________________________________                                                                                   I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information  may be shared by the various care providers involved in my care and treatment.                                                      ___________________________________________________                                                                         Treatments may be covered by extended health care plans. I understand it is my responsibility to confirm the exact details of my coverage.                                ___________________________________________________                                                                       Please type your name and today's date below if you agree to the terms: *
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