QUEERFLEX Massage Intake - NEW CLIENT
This is an intake form for QUEERFLEX clients utilizing our massage therapy service for the first time. You MUST be a QUEERFLEX Member to access this service. Membership options can be found at https://www.queerflex.com/membership/
Email address *
Are you a QUEERFLEX Member? *
Preferred Name *
Your answer
Pronouns you use *
Your answer
Phone number *
Your answer
Emergency Contact: Name, phone, their relation to you, and whether or not it is ok for us to you your preferred name and pronoun you use with that person if we have to contact them (if it is not, please note name and pronoun you would like us to use) *
Your answer
What have your past experiences been like with massage therapists and body workers (If none, put "none")? *
Your answer
Type of massage you would like: Table(under sheet to personal comfort level) *
Any injuries our massage therapist should know about? (Please list anything past or present. If none, put "none"): *
Your answer
If you have been in any high-impact motor vehicle accidents, please note date and any injuries sustained (If none, put "none"): *
Your answer
If you live with any illnesses, bone/joint issues, experience muscle spasms, or have any mobility considerations, please list them here (If none, put "none"): *
Your answer
Do you where a chest binder (If yes, please note for how many hours per day, on average)? *
Your answer
If there are any other accessibility considerations you would like us to know about, please list here (If none, put "none"). *
Your answer
Appointments are on select Saturday's ONLY between the hours of 11am-8pm and are unto 90 mins in length. Please innate which time-frame you would prefer for your appointment: *
Do you have access to health benefits through your work? *
Is there anything else you would like your massage therapist to know? *
Your answer
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