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Client Intake
Please answer the following questions as fully and accurately as possible. This form is HIPAA compliant- suitable for use in healthcare and all information will be kept private.
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Email *
Today's Date *
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Date of Birth *
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Address
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Name: First, Last
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Pronouns
Phone number
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How did you hear about me?
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Emergency Contact and phone number
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How do you spend your time? (occupation, hobbies/exercises/etc)
What are you goals for massage?
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Are you currently feeling any pain, tension, discomfort, etc. in particular areas of your body? If so, where? Do you have any past or current injuries or chronic conditions? *
Are you pregnant?
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Have you had any surgeries or internal procedures completed?
Are there any areas of your body that you do NOT want massaged?
Please list any regular medications
What length of massage are you interested in?
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I accept checks made out to Esther Baker-Tarpaga or venmo or paypal or cash. Please indicate your method of payment.
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I typically use a massage oil that I make from shea butter and coconut oil with Lavender, Geranium, Eucalyptus, and Tea tree essential oils. Please let me know if this is ok?  If you have any allergies I can use plain coconut oil, or a cream you use on your skin typically. I can also do no oils/cream.
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If you are experiencing financial hardship and would like a sliding scale rate please indicate here and how much you are able to pay for a session- indicate time and fee.
Have you read and do you agree to all policies? https://www.madronemassage.com/policies
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I authorize Esther Baker-Tarpaga to perform the treatment or necessary procedure for myself. I authorize the use of lotion, oil, and ointments to the body. I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the masage.  I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician. I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited. I release Esther Baker-Tarpaga for any responsibility in case of an accident, illness, or injury. I acknowledge that all information I provided in this form is true and accurate with my signature below.*
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A copy of your responses will be emailed to the address you provided.
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