Relaxation Therapy
New Patient Intake Form
Client Information
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer Details
Employer Name
*
Company Name
City and State
Phone Number
*
-
Area Code
Phone Number
Health Data
Do you have any allergies?
*
If yes, please specify on the field above.
Are you currently taking any medications?
*
If yes, please specify on the field above.
Are you pregnant or nursing? (Female only)
If yes, please specify on the field above.
Do you have any current injuries?
*
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
*
If yes, please specify on the field above.
Location of painful areas
*
Consent and Waiver
*
I authorize the use of lotion, oil, and ointments to my body.
I understand that I should consult my physician for any life threatening medical emergencies.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
I release this therapist from any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided int his form is true and accurate.
Signature of the Client
*
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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