New Client Intake & Covid Consent Form
Zoë Kosovic, CMT, RYT
Name
First Name
Last Name
Your pronouns
Date of birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Preferred contact method
Text
Email
Phone
Address (used only for driving directions to in-home appointments)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parking instructions (for in-home sessions only)
I am interested in
Massage
Reiki
Yoga
Sound healing
Other
What are your service preferences?
Therapist's location
In-home
Weekdays
Weekends
Morning
Afternoon
Evening
What are your health goals and how can I assisting you in achieving them?
What are your main reasons for seeking massage or yoga?
General wellness
Injury recovery
Relaxation
Pain management
Other
Occupation
Please list your daily activities such as work, exercise, home rituals, relaxation practices, habitual movements...
Are you currently experiencing any of the following?
Pain or tenderness
Stiffness or limited mobility
Numbness or tingling
Swelling
Allergies
Inflammation
Other
Please list any allergies or skin sensitivities
ex: almond oil, essential oils, animals
Please list all injuries, illnesses, surgeries, and health concerns you have had in the past 3 years, or those that restrict you in any way
ex: arthritis, shoulder surgery, car accident, diabetes, skin condition, low blood pressure, traumatic birth etc.
Please list any prescription or OTC pain relievers you have taken this week
Are you pregnant?
No
Yes
Trying
Emergency contact name and phone number
Would you like to receive occasional updates from my practice? I send out a monthly-to-seasonal newsletter to keep clients abreast of any changes to my availability, Covid protocols, offerings, and things that I am finding helpful that you might benefit from as well.
Yes, please
No, thank you
I have provided all known medical information. I acknowledge that massage therapy/ energy work/ yoga is not a substitute for medical diagnosis and treatment. I give my consent to receive treatment. Please type your full name:
I acknowledge I am consenting to receive a strictly professional and therapeutic massage/ yoga lesson. Absolutely no inappropriate, suggestive or sexually threatening conduct or language will be tolerated. Should this condition be violated, the session will be immediately ended. Please type your full name:
Cancellation policy: At least 24 hours cancellation notice is required for all bookings. A 50% charge will apply to all bookings cancelled within the 24 hour window, due at the time of cancellation. In acknowledgment, please type your full name here:
Covid consent: I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. Please type initials:
I understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID-19 have been implemented. However, because massage therapy involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID-19. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this treatment and give my express permission to the practitioner (Zoe Kosovic) to proceed with providing care. Initial:
I agree that I will notify the practitioner (Zoe Kosovic) if I test positive for COVID-19 and have received a massage in the last 14 days. I understand in the event this happens, my contact information may be shared with the Department of Health and other entities as needed. Initial:
Submit
Should be Empty: