Massage
Client Intake Form
Name
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First Name
Last Name
Contact
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Phone Number
Email Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
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Month
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Day
Year
Date
Employer / Occupation
Employer
Occupation
Emergency Contact
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First Name
Phone Number
How did you hear about Sherrielee Holistic Skin Spa?
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Have you ever had a relaxation massage before?
Yes
No
If you've had a massage before, when?
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Month
-
Day
Year
Put today's date for No.
Are you Pregnant? (please note, I do not do pregnancy massages and I will have to refer you to a LMT. (Licenced Massage Therapist.)
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Yes
No
Please initial that you are not pregnant.
*
Put today's date for No.
Please initial that you understand that I am a Licensed Esthetician and licensed to do a “Relaxation Massage” only. I am NOT a licensed massage therapist (LMT) and cannot perform deep tissue massage.
*
What result do you want from your treatment today? (please click all that apply)
Stress Relief
Relax
Promote Greater Relaxation
Reduce Anxiety
Improve Overall Sleep Quality
Deep Meditation
Please check if you currently have any of these conditions. (please click all that apply)
*
Anxiety
Auto Immune Disorder
Arthritis
Back Problems
Diabetes
Hypertension
Hypotension
Jaw Pain (TMJ)
Kidney Disease
Migraines
Muscle Spasms
Neck Problems
Pace Maker
Osteoporosis
Recent Surgery
Respiratory Problems
Sleeping Disorders
Varicose Veins
No conditions, I love massages!
Do you have any medical conditions or allergies I should be aware of not listed?
*
Yes
No
If any allergies, please describe:
Any accidents, injuries or illnesses still effecting you?
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Yes
No
If any accidents, injuries or illnesses, please explain.
Client Signature
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I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s or sherrielee skincare part should I forget to do so. I understand that massage is entirely relaxation and non-sexual in nature. By signing this release, I hereby waive and release my therapist and sherrielee skincare from any and all liability, past, present and future relating to massage therapy and bodywork. By signing this release, I hereby declare that I have provided the therapist with all relevant information necessary for the proper application of massage therapy and I expressly give permission for the therapist to provide massage therapy. I am a Licensed Esthetician and licensed to do a “Relaxation Massage”. I am NOT a licensed massage therapist (LMT) and cannot perform deep tissue massage. If you have a serious injury I will refer you to a massage therapist.
Today's Date
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Month
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Day
Year
Date
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