Massage Art - intake form
- WE CAN ASSIST BEST WITH THE MOST INFORMATION :-) THANK YOU!
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Email *
Name (new clients show ID) *
Age *
Under 21
Later retirement age
Phone
Email
Street address *
City
Clear selection
Zip Code *
Emergency Contact Nm & Ph
How did you find us?
Clear selection
Last time you had massage or physical therapy work *
Within the last 2 weeks
Never
How often do you seek massage/ therapy ?
Under 4x per year
1x/ week or more
Clear selection
Occupation &/or cause of therapeutic need
Areas of need *
Required
Any area painful/ sensitive to touch? *
Any perfume/ scent allergies? *
Atmosphere preference
Complete silence
Quiet music & light conversation
Clear selection
Known conditions or symptoms I have/ had
Acknowledgement ~ I have completed this form honestly & to the best of my knowledge. I understand services are as therapeutic health aid. The modalities provided compliment a healthy lifestyle. They are not to replace physician's care, hence, diagnostic or medications are not prescribed. Often, multiple sessions are required to facilitate the most beneficial plan for the body's needs to heal. Any information exchanged during a session is completely confidential and is only used to provide best Healthcare Services. If I am unable to make a scheduled appointment I agree to cancel the appointment within 24 hours in advance unless I have an emergency. In this case I will call ASAP to reschedule. If I miss a scheduled appointment without giving 24-hour notice I agree to pay any missed appointment fees applicable. However if I neglect to cancel to show for my scheduled appointment without any notification I agreed to pay for the cost of the full session.   NAME (type as signature): *
Today's date: *
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