Relief Therapy - Christopher Pierce: Client Intake and Release
Your Private Health Information (PHI) is important and information submitted via this form to Relief Therapy - Christopher Pierce ("Christopher", "Chris", "I", "me") is protected under HIPAA with a BAA via Google Services. What this means is that PHI submitted in this form is kept private according to regulations under HIPAA. For more specific information and questions contact
or refer to
Preferred Full Name
Date of Birth
10 digit number. No symbols or spaces.
Is it OK to text this number?
I sometimes work with a personal booking assistant (PA) or other companies. Texts are for scheduling reminders, confirmations, etc. This is subject to your data plan.
Yes, from anyone
Yes, from me or my PA
Yes, from me only
This is the email you want me to use for sending schedule confirmations, reminders, etc.
With unit number (outcall clients need to fill out this field)
Do you take anything regularly?
Both every day or as needed medications should be listed, and recent use should be disclosed before the start of each session. Also list any regular injection sites (diabetes, hormones, etc.). Write "No" instead of leaving blank.
Do you have any ongoing health concerns?
Especially conditions related to your muscle, heart, blood, brain, or skin. Don't list past or current injuries, or temporary illnesses, here. If detailed, we can discuss more in person. Write "No" instead of leaving blank.
Do you have any significant past or current injuries, illnesses, surgeries, or conditions not yet listed?
This is collected for awareness of scar tissue, limited mobility, etc. You do not need to list anything which you feel fully recovered from unless it affects your movement, pain, or immune system. If detailed, we can discuss more in person. Write "No" instead of leaving blank.
Do you have any allergies or sensitivities to oils, scents, latex, or medications?
Medication allergies (like for penicillin) are collected in the rare case of emergencies. Write "No" instead of leaving blank.
Contact and Billing Info
Your privacy is important to me, and I will never sell or share your information to a third party without your consent. Because I often work with third parties, rather than making you re-enter information I already have for scheduling and billing purposes, it can be more convenient for you if I do it. However, I can not always guarantee how other parties may use that information (promotions, billing disputes, etc.), so I want to be sure you are in control. If you do not want me to share certain information preemptively, I will only reach out to you to either let me share that info, or direct you to where you can enter it yourself, as needed.
You may always preemptively share my contact and billing information with 3rd parties for my scheduling and billing convenience.
You may only preemptively share my contact information.
I'd prefer to only give out my information as needed.
for Relief Therapy - Christopher Pierce (DO NOT CHANGE)
By typing my full legal name below, I am requesting to receive massage and understand that massage therapy is not intended to treat or diagnose any disease and any information I receive is for general knowledge and should not be considered medical advice. I acknowledge that there are some risks associated with massage, including, but not limited to, bruising, muscle pain, or the exacerbation of pre-existing conditions. I release Christopher, and any companies he associates with, from all liability regarding these risks during the massage session. I understand it is my responsibility to inform Christopher of health changes, and any discomfort during or after the session.
Legal Full Name
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