Client Intake Form

Client Intake Form (read carefully)

All information is held in the strictest confidence. At no given point is information disclosed or shared without client’s written consent. Please be truthful in your answers for a safe and much more comfortable professional experiecnce.

Women should not receive a massage in their first trimester but after their first trimester it is recommended to receive prenatal massages 1x somwtimes 2x a month. It is also recommended to receive a manual lymphatic massage 7 days after birth to release any water retention and inflammation.

For body sculpting services, usual wait is 9 months-1 year after birth.

Consult with your physician if interested in receiving other treatments.

PLEASE READ POLICY AND AGREEMENT CAREFULLY BEFORE SUBMITTING FORM. BE SURE YOU UNDERSTAND AND IF YOU HAVE ANY QUESTIONS PLEASE FEEL FREE TO ASK.

Full Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number

Format: (000) 000-0000.

This is my:

E-mail

example@example.com

Emergency Contact

Phone Number

Format: (000) 000-0000.

Medications

Allergies

Questions below MUST be filled out.

1. List and describe areas of discomfort or pain.

2. Rate of Pain Today

3. Have you ever injured this area before? Any treatments? Effective?

4. List all surgery or treatments received overall and was it effective?

5. Have you ever been in an accident and when (automobile, work, falls, etc.)?

6. What are the physical duties required of your occupation?

7. Pregnant? If so, how far along?

8. If you were referred, by who? Where did you hear about us?

9. Have you ever received a massage? How often?

Policies for all services:

Deposit is required to schedule appointment
NO refunds
Intake forms must be filled out by first time clients
Please arrive 5-10 minutes early for a quick consulatation before and after every session
If you are running late, you will not be serviced for your full time, only the remainder and will still be charged full service
Do not drink or eat 2 hours prior to your services
Please be considerate and shower before your session
You will be draped with sheets and at no time will genetilia or breast tissue be exposed
Once therapist leaves room after instructing you what to do regarding disrobing, you may choose the option that best suits the level of your comfort
I understand that my therapist can end the session at anytime for any reason
Inappropriate behaviour will NOT be tolerated and will result in being prosecuted to the full extent of the law

Client Agreement:

I understand that my therapist does not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment and pharmaceuticals.

I acknowledge that these services are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic massage as a form of therapy.

I also undersand that at any time I feel pain or discomfort during any services, I will immediately inform my therapist so they can adjust.

I have provided my medical and health history including any medications I am currently taken or have in the past. It is my responsibility to update my form and therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless YestohealingLLC and my therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the policy and client agreement above.

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.