New Guest Intake Form
Email address *
Name *
Your answer
Birthday *
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Address *
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Phone *
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Occupation
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How did you hear about me? *
Your answer
Are you taking any medications, if yes, please list below *
Your answer
Are you currently pregnant? *
Do you suffer from chronic pain? If yes, please explain
Your answer
Have you had any orthopedic injuries? Please list
Your answer
Please indicate any of the following that apply to you *
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Explain any condition you have marked above
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Have you had a professional massage before? *
What type of massage are you seeking?
What pressure do you prefer? *
Do you have any allergies or sensitivities? Please, explain *
Your answer
Are there any areas (feet, glutes, abdomen, face, etc.) we should avoid? *
Your answer
What are your goals for this treatment session?
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I understand that unanticipated events happen occasionally in everyone’s life and are happy to honor your business as follows: If there are any health issues present at the time of your scheduled massage that might make massage a bad idea, including fever/cold/flu/sickness, please contact me BEFORE arriving for your massage. If you are pregnant at the time of your massage appointment, please contact us BEFORE arriving for your massage. A 24-hour advance notice is required when cancelling a massage appointment. This allows the opportunity for someone else to schedule an appointment. Since all massage services are by appointment only, a major credit card is required to hold your appointment. You will not be charged until massage services are rendered, unless you fail to cancel within 24 hours and/or no-show (see below) your appointment! If you are unable to give 24 hours advance notice you will be charged the full amount of your appointment. Anyone who fails to show up for a scheduled massage and does not provide 24 hours cancellation notice, will be considered a “no-show” and will be charged the full amount for the missed appointment. Out of respect and consideration to other clients, please plan accordingly and be on time. If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, I will determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the “full” session.
Your answer
By electronically signing and submitting below, you agree to the policies stated above and the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist, Brenda, if any of the above information changes at any time.
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