Basic Intake
Name
First Name
Last Name
Date
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Month
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Day
Year
Date
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Date of birth
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Month
-
Day
Year
Date
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Phone Number
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Area Code
Phone Number
Email
example@example.com
Would you like to join Abby's mailing list?
yes
no
When was the last time you received massage?
What is your main reason for booking an appointment?
Do you have any allergies? Topicals/skin, airbornes, medications etc.
Are you sensitive to incense smoke?
Are you pregnant? If so, how far along?
Are you on any medications? If so please list, including what they are for.
Do you have any injuries?
Any areas you would like focused on?
Any areas you would like avoided or to be cautious around?
Anything else you would like to add?
Client confidentiality and release agreement
I understand that all modalities offered by Abby Kenny are not replacements for medical care. The practitioner, a licensed massage therapist, does not diagnose or treat mental or physical illness, disease or other physical or mental conditions. As such, the practitioner does not prescribe medicines, nor does she perform spinal manipulations. By choosing to work with AbbyKenny, It is my, the client’s responsibility to consult the appropriate licensed health care professionals for treatment of any mental or physical disease, symptoms or concerns that I may have. I agree to take responsibility for my own health and my own response to massage therapy and I agree not to hold the massage therapist responsible for any unwanted results in my life after receiving a massage from her. The practitioner may recommend referral to a qualified physical or mental health care professional for any physical or emotional conditions I may have that are out of her scope of practice. The practitioner may recommended self care routines that may regard food, flower essences or herbal practices and it is up to you to research and decide what is suitable for you. By signing this you acknowledge that it is your responsibility to check with your doctor to verify what it is suitable for you and you will not hold Abby Kenny orSubliminal Bliss responsible for any unwanted results. I have stated all my known physical and mental conditions and take it upon myself to keep the massage therapist updated on my health status. The information I provided in this form is accurate and true to the best of my knowledge. Missed appointments without 24 hour notice are subject to the cost of the appointment that was missed.
Please check to confirm you have read and agree to the above terms and conditions.
Please check to confirm you have read and agree to the 24 hour notice cancellation policy.
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