New Client Intake Form

New Client Intake Form

For massage therapy, assisted stretching and bodywork
Name*

First NameLast Name
Email*
Phone Number*
Address*

Street Address

CityState / Province

Postal / Zip Code
Occupation
DOB *

MonthDayYear
Is this appointment/paperwork for a minor? If yes, parent/guardian input your information in Emergency Contact below*

YesNo
Emergency Contact Name & Number
Who referred you / How did you find me?*
(Google search, social media, referral)
If you are taking medications for pain management or cardiovascular disease control please list them here:
Painkillers/anti-inflammatories, ACE inhibitors, Beta or Calcium channel blockers, blood thinners etc
Any allergies? (oils, nuts, fruits, skin, etc)
Are you pregnant or nursing?
How many months / Due date / etc
Please list any 1) recent injuries 2) medical procedures in the past 2 years and 3) joint replacement(s) as well as any other pertinent medically related concerns:
Have you had professional massage/bodywork before?

YesNo
If yes, what type & when was your last session?
Reason for seeking massage/bodywork:*
Relaxation / Specific problem or pain - please be detailed in your response to ensure your session is customized to your specific wants and needs.
For massage, how much pressure do you prefer? You can select more than one; we will discuss preference(s) at time of session.*

LightMediumFirmDeep
By sumbitting this form you agree to the following:

Zero Tolerance Policy:

I understand this massage/bodywork is for therapeutic purposes and any sexual remarks, jokes, and advances will be taken seriously. I will be fully draped during massage sessions, and my therapist will only uncover the area being worked on. I will remain full dressed for other bodywork sessions. Failure to respect this policy will result in termination of my session, and I will be liable for full payment of the scheduled treatment.

Cancellation Policy:

I understand all changes or cancellations of an appointment that are not made within 24 hours of the appointment time, will be subject to a cancellation fee of the full appointment cost.

If the card I provided to hold my apointment is unable to be charged for the cancellation or no-call/no-show fee, an invoice will be added to my account, and I will be liable for the payment at my next appointment time.

Treatment of a Minor:

If this session is for a minor and this paperwork is being completed for said minor, by signing below, you acknowledge that you are the parent/legal guardian of the minor who is to recieve massage/bodywork at this facility. You acknowledge that you have read and understand all information on this form and authorize this practice to provide therapeutic massage and bodywork for your child/dependent.

Final Statement:

I have completed this form truthfully, and to the best of my ability and knowledge, and agree that I understand the benefits and risks of massage/bodywork and that I will inform my therapist if any of the above information changes at any time.
Signature

Clear
Date*

MonthDayYear
Should be Empty: