Client intake form TM30A

Confidential Client Intake Form

(FOR NEW CLIENT ONLY - close this window if you have already filled this form before)
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Occupation
Emergency Contact name*
Phone Number*
Format: (000) 000-0000.
Relationship
Relaxation/ stress reductionTargeted bodywork, pain managementOverall Body Maintenance (i.e. Flexibility, Circulation, etc)Other, Note
What is your focused area for this treatment
Do you participate in any repetitive physical activities that may results for this visit? (i.e. lifting, sitting for long hours, computer work, driving)
Light : RelaxingMediumMedium to FirmHurt me!
NoYes, explain
NoYes, explain
NoYes, explain
NoYes, explain
OsteoporosisHerniated DiscFractureVaricose veinsHeart conditionBlood clotsArtificial jointsStrokesArthritisSeizure/epilepsyPregnancyCancerOther
Other notes
Agree
Agree
Agree
I understand that the massage I receive is provided for the basic purpose of relief of muscular tension and relaxation. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or technique may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the massage therapist updated as to any changes in my medical profile during the session and understand that I shall assume all liability for damages sustained as a result of my failure to provide the massage therapist with any changes. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and/or loss of service privileges. I also understand that the Licensed Massage Therapist reserves the right to refuse to perform massage on anyone who he/she deems to have a condition for which massage is contraindicated.*

Agree
I have read, understand, and agree to the above policies and information.
Date*

MonthDayYear
Date
Thank you and see you soon!

Mona - Thai Massage of 30A
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Confidential Client Intake Form