Serenity Now Intake Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Referred By

Date of Initial Visit

Date

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

Physician's Name

Physician's Phone

Please enter a valid phone number.Format: (000) 000-0000.

How would you rate your general health?

Have you had a professional massage before?

If you answered yes, when was the date of your last treatment?

List current medications & the conditions they are treating

List any major accidents or surgeries (including dates)

Please tell us about any allergies or hypersensitivities

Reason for initial visit

Head/Neck

Cardiovascular

Respiratory

Nervous System

Skin & Infections

Musculoskeletal System

Reproductive

Other Conditions

I understand that if I am experiencing any COVID symptoms that I will have to reschedule at no cost. During these times of COVID, I am implementing the following procedures guided by the NC massage board, to protect my clients, their families, and mine. The procedure is as follows:

1st, remain in your car until I signal you to come in.

2nd, I will greet you at the door with hand sanitizer and will take your intake form at this time

3rd, I will take your temperature at your temple.

4th, mask are optional.

I understand that close contact with people increases the risk of infection of COVID. I acknowledge that I am aware of the risks involved and give consent to receive a massage from Rose Ortiz.

Signature

Date