NEW CLIENT INTAKE AND LIABILITY FORM

Full Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Type of appointment:*

MOBILE (Enter your address below)IN-OFFICE (Vibe28 Location - 10960 S. Eastern Ave #101, Henderson, NV)

Mobile - Address Where Appointment Will Be Held

Street Address

Street Address Line 2

CityState

Zip Code

Gate Code

if applicable

Date of Birth:*

Date

E Mail:*

example@example.com

Would you like to receive marketing emails including package rates, updates, and helpful fitness and wellness tips? Never spam.

Yes, send me the deals!

Occupation:*

Emergency Contact Name:*

Full NameRelationship

Emergency Contact Phone Number*

Please enter a valid phone number.

Referred By (where did you hear about me?):

Name

What specific goals would you like to achieve from manual therapy/ sports massage/ bodywork/ movement coaching?

Please list any injuries you currently have:

Are you currently or have you ever been under medical supervision for any of the injuries you listed above?

Have you ever had any tests for any of the injuries listed above? (ie. X-Rays, MRI, CT Scans?)

Have you ever had chiropractic treatment, physical therapy, or anything similar? If yes, for how long, how often?

Describe any major symptoms your are currently experiencing. Please choose all that apply:

What makes your symptoms worse or better?

On a scale of 0 to 10 with 10 being the worst imaginable discomfort, what is your discomfort level right now?

Are your symptoms worse during a certain time of day? (ie. worse in the morning, or at night)

What physical activities are you currently involved in? (ie. what sports, types of workouts, work is physically demanding, etc.)

What are your current recovery practices? (stretching, foam rolling, massage gun, breathing exercises, etc.)

Have you experienced any type of bodywork before? (ie. Massage, acupuncture, dry needling, cupping, scraping, etc.)

Do you wear any type of supportive braces? Do you wear orthotics (shoe inserts)? If yes, for how long?

What percent(%) of your day is spent SITTING?

What percent(%) of your day is spent STANDING?

What percent(%) of your day is spent DRIVING?

Please list any RECENT illnesses or surgeries:

Are you currently under the care of a physician?

Have you EVER had any major surgeries? If yes, please explain.

Please list current medications, including aspirin, ibuprofen, etc.

Have you had any physical accidents? (auto, at work, or other)

Have you had any head injuries?

Have you noticed any recent dizziness?

Have you noticed any recent change in vision?

Have you noticed any recent change in hearing?

Please check all that apply to you:

Are there any other medical conditions that the therapist should be aware of?

Are you pregnant? If yes, how far along?

By signing below you agree to the following:

The above information is accurate and true to the best of my knowledge. If there are any changes in my current level of health, I will inform the massage therapist (Dana Husted, dba Dana Husted Therapy), of my condition. I understand that Dana Husted dba Dana Husted Therapy does not diagnose or treat illness or disease and does not prescribe medications. I agree to pay my account with Dana Husted dba Dana Husted Therapy in accordance with the regular rates and payment terms established. If, for any reason, cancellation is necessary, I will give a 24-hour notice via text or phone call to Dana at 702-985-4597. I understand that if I do not give this notice in this timeframe, I will be charged for the full appointment. It is agreed that any claim of any liability is hereby waived.

1) I give my permission to receive massage therapy.

2) I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.

3) I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications.

4) I have clearance from my physician to receive massage therapy.

5) I understand the risks associated with massage therapy include, but are not limited to: Superficial bruising, Short-term muscle soreness, Exacerbation of undiscovered injury

6) I therefore release the company (Dana Husted Therapy) and the individual massage therapist (Dana Husted) from all liability concerning these injuries that may occur during the massage session.

7) I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition.

8) I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly.

9) I understand that I or the massage therapist may terminate the session at any time.

10) I have been given a chance to ask questions about the massage therapy session and my questions have been answered.

11) Privacy Policy https://www.danahustedtherapy.com/privacy-policy

Current Rates as of June 2023:

$150/ 60 min session

$200/ 90 min session

$250/ 120 min session

CANCELLATION POLICY*

A MINIMUM of 24-hour cancellation notice is required via text or call (702)985-4597. NO EXCEPTIONS. If notice is not given within the 24-hour timeframe, you will AUTOMATICALLY BE CHARGED the ENTIRE AMOUNT OF THE SESSION. The payment is non-transferable and cannot be used for rescheduling. The payment will also include a service fee for using credit. If notice IS given properly per the policy, any deposit previously made can be transferred to a new date.

Signature (Parent/ Guardian if client is under 18 years)*

Printed Name*

First NameLast Name

Today's Date*

Date

Bodywork/ Massage - NEW CLIENT INTAKE AND LIABILITY FORM