Client Intake Form
Please provide health history. Your email address and contact information will not be sold or given to any third party.
Email address *
Name *
Your answer
Address
Your answer
Cell Phone # *
Your answer
Date of Birth *
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DD
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YYYY
Occupation
Your answer
Emergency Contact Name & Phone Number *
Your answer
Referred By
Your answer
When was your last massage?
MM
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DD
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YYYY
Select any areas you want to be FOCUSED on
Select any areas you want to AVOID
Please mark all current and past conditions
List any medications you are currently taking you think your therapist should be aware of
Your answer
DISCLAIMER
This place of business will not be help liable or any injury or condition that arises from application of massage despite completion of this form. The form is intended as an assessment tool only and serves as a guide for the application of massage not for medical treatment or medical assessment. Draping will be using during this session. Only the body areas being worked on will be uncovered. Breast massage on female clients will not be performed without written consent of the client prior to massage. Clients under the age of 18 have a parent or legal guardian present to provide a signature for authorization for the therapeutic massage session.
CANCELLATION POLICY
By signing this intake form you agree that if you need to cancel or reschedule an appointment you will have until 24 hours before your scheduled appointment to cancel to avoid being charged a cancellation fee of $35.00. Any same day cancellations, not showing up to your appointment and changing your appointment the same day will result in a full charge of the session unless otherwise decided upon by your therapist.
ACKNOWLEDGMENT
I have stated all conditions that I am aware of and this information I provided is true and accurate to the best of my knowledge. I agree to inform my massage therapist immediately of any change in the conditions stated above. I understand that any illicit or sexually suggestive remarks or advances made by myself will result in immediate termination of this session, and I will be liable for full payment of the appointment
Client Signature - Please enter your full name acting as a signature for this form.
Your answer
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