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M.I.A The Elite Relaxation Specialists

Massage Therapy Consent & Client Intake Form
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    • Afghanistan
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    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
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    • Bahrain
    • Bangladesh
    • Barbados
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    • Belize
    • Benin
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    • Bolivia
    • Bosnia and Herzegovina
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    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
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    • Dominican Republic
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    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
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    • Ethiopia
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    • Faroe Islands
    • Fiji
    • Finland
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    • French Polynesia
    • Gabon
    • The Gambia
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    • Greece
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    • Grenada
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    • Guam
    • Guatemala
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    • Guinea
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    • Guyana
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    • Hungary
    • Iceland
    • India
    • Indonesia
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    • Iraq
    • Ireland
    • Israel
    • Italy
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    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
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    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
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    • South Ossetia
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    • Spain
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    • Sudan
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    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
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  • 16
    0=less than a year
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    This can be a rough estimate or exact. If you have had more than 100 massages then use the '100+'
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    Choose all the ones that apply
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    Choose all that apply
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    Choose all that apply5
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    Please spare no details. We want to make sure we have all the necessary information for your massage therapist to best recommended their professional option
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    Please spare no details. We want to make sure we have all the necessary information for your massage therapist to best recommended their professional option
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    Please spare no details. We want to make sure we have all the necessary information for your massage therapist to best recommended their professional option
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    Please spare no details. We want to make sure we have all the necessary information for your massage therapist to best recommended their professional option. Yes this is all past surgeries not just spine or head concussion.
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    Tap ADD MORE to enter another doctor and their information in the next.
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    Choose all that apply
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    Example Line One: Cancer diagnosed 4/3/1999
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    Example: Botox, fillers. The reason we ask is to make sure it is dually noted in your profile so that we can avoid that areas if it is still tender.
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    0 being no pain at all and 10 being the worst pain you have ever felt
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    Choose all that apply or let us know what specifically you would like
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    Choose all the areas you would like to focus on the head
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    Choose all the areas that would apply to your neck
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    Choose all the areas you want to focus on and that apply
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    Choose all the areas that would apply to your Mid-Back
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    Choose all the areas that would apply to your Hips
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    Choose all the areas that would apply to your Low Back
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    Choose all the areas that would apply to your Low-Back
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    Choose all the areas that would apply to your Legs or Feet
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    Choose all the areas that would apply to your legs and feet
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    Choose all the areas that would apply to your Legs or Feet
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    In each line enter the dates and more information then ADD MORE to add another injury or incident
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    (automobile, work, falls, etc.) ?
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  • 82
    On each line enter the date and type of injury with related treatment received for this injury and then tap ADD MORE to add more past accidents
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  • 83
    If yes, please give date of last massage.
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  • 84
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    On each line enter the date and type of injury with related treatment received for this injury and then tap ADD MORE to add more past accidents
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    If yes, please explain.
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  • 90
    Please list each occupation and add more if need be.
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  • 91
    Please list each physical duty required on each line
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    Clear
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