Intake Form

Windows of Wellness Intake Form
Personal Information
First Name*
Last Name*
Full Name*

First NameLast Name
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
E-mail*
example@example.com
Employer*
Occupation*
Marital Status*
Spouse's Name
Spouse's Employer
Spouse's Occupation
Number of Children
Children's Names, Ages
Emergency Contact*
Emergency Contact's Phone Number*
Primary Care Physician*
Primary Care Physician's Phone Number*
How were you referred to our office?*
Financial Information
How I plan to pay for therapy:*

CashCheckCredit CardGift CardHSA/FSA Card
Cancellation Policy

Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater flexibility to all our clients. We hope this will alleviate any stress and hesitation you have about an upcoming appointment. If you need to reschedule for whatever reason, and especially if you are not feeling well, we understand and request for you to please contact us as soon as possible to reschedule. To further support you, there will be no penalties for cancellations at this time.

However, if you do not show up for your appointment and do not notify us in advance that you need to cancel or reschedule, no shows will still be charged a $25 fee. If you are on a package or annual membership, you will forfeit that session of your package or membership.
Credit Card to Hold/Secure an Appointment

As a new client, we require a credit card to be held on file to secure your appointment. If you do not show up for your appointment, or do not provide at least 24 hours notice should you need to cancel or reschedule, you will be charged a $25 fee. That fee will automatically be charged to the credit card number you provide below.

The credit card number provided below will only be charged if you do not show up or provide adequate notice of a cancellation - no payment is being made upon completion of this Intake Form. When you arrive for your appointment, you will be able to use your preferred payment method (cash, check, credit card, gift card, etc.) to pay for your session.

No Show

$1.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

History of the Present Problem
Purpose of this appointment:*
Have you ever had the same or a similar problem?

YesNo
If yes, please describe:
Please refer to the image below for the next question.
The Sections I have pain (Check All That Apply)

Section ASection BSection C
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?*
If so, Please Explain.
Do you have any particular goals in mind for this massage session?*
If so, Please Explain.

Social History
Do you do any of the following? (Please check all that apply)*

ExerciseUse tobacco productsConsume caffeineSleep well at nightDrink alcoholTake vitamin supplementsNone of the above
If you checked any of the options above, please detail below:
What are your hobbies?*

Signature and Submission
Please sign your name below to indicate consent to treatment.
Patient's Signature*

Clear
Date

MonthDayYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Enter the message as it's shown*
Should be Empty:

Windows of Wellness Intake Form

Personal Information

Financial Information

Personal History

History of the Present Problem

Please refer to the image below for the next question.

Social History

COVID-19 Health Information & Informed Consent

Signature and Submission