NyxHealingHands

Client Intake Form

Please complete this form at least 24 hours before your scheduled session.
Select your therapist:

Nyx MT-26938Ash MT-26937No preference
Name*

First NameLast Name
Preferred name/ Nickname
Gender

FemaleMaleNon-binaryOther
Pronouns

He/ himHer/ sheThey/ themOther
Occupation
Birthday

MonthDayYear
Phone Number

Area CodePhone Number
Email
How do you prefer we contact you?
May I text you?

YesNoOther
May I email you?
How did you hear about us/ Referred by:
Every 2 referrals gets them a free service!
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact
Name
Emergency Contact Phone Number

Area CodePhone Number
When was your last massage?
What type of pressure do you prefer?
What is more important to you?
Will you be able to make a space approximately 6ft by 8ft for our session?

I can have the space readyChair massage pleaseOther
A deep, therapeutic massage can leave you feeling sore for a day or two. How do you feel about being sore after your massage?
What are your current problem areas & how are they affecting you?
What are your top priorities to be addressed at your appointment?

Low Back PainSciatic PainNeck PainHip PainTight Glutes (Butt Muscles)Shoulder IssuesTension HeadachesOther
How long have you been experiencing these issues?
What type of pain are you currently experiencing?

Stabbing PainShocking/ElectricBurning PainAchy PainWidespread Pain & TendernessMuscle SpasmsTension PainLocalized/Small AreaNoneOther
How did your issue/pain begin?

SlowlySuddenlyIt has gotten worse over time.It has improved over time.I'm not sure how it happened or how it progressed.Other
In your entire lifetime, have you ever had any of the following surgeries?

NoneOrthopedic SurgeryCarpal Tunnel SurgeryRotator Cuff SurgeryNeck / Back FusionKnee SurgeryHip ReplacementAnkle SurgeryGallbladder SurgeryHysterectomyAppendectomy (Appendix Removal)Breast SurgeryLymph Node Removal
Please list any other surgeries, recent body or head injuries, or medical implants:
Do you have any special needs I should prepare for?
Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medical pump)?
Are you currently pregnant?
Sensitivity to Smells?

NoneEssential oilsIncenseSmokeOther
Allergies?

Cat danderCottonPolyesterCertain lotionsEssential oilsOther
Which medications are you currently taking?

I am NOT taking any prescription medications.Otc. Aspirin/ Ibuprofen/ Tylenol/etc.Blood thinner.Other
Skin Conditions?

PsoriasisEczemaSkin tagsCellulitisOther

Medical History

	Current	Past
Car Accident*
Blood Clots*
Congestive Heart Failure*
Unexplained Calf Pain*
Varicose Veins*
Stroke or Heart Attack*
Cancer*
High Blood Pressure
Low Blood Pressure
Epilepsy / Seizures
Chronic Headaches / Migraines
Chronic Dizziness / Ringing Ears
Digestive Disease (IBS, Crohns, etc)
Chronic Constipation
Chronic Diarrhea
Kidney Disease / Chronic UTI's
Arthritis (rheumatoid, osteoarthritis)
Scoliosis / Kyphosis / Lordosis
Osteoporosis
Degenerative Spine / Disk
Broken Bone
Allergies that Require an Epi-Pen
Autoimmune Condition (Celiac, Hashimotos, Lupus, Graves, etc)
Diabetes / Insulin Resistance
Endocrine / Thyroid Condition
Chronic Depression
Chronic Anxiety
Chronic Swelling
Sensitive to Touch / Pressure
Easy Bruising
Shortness of Breath / Asthma
Chronic Muscle / Joint Stiffness
Chronic Muscle / Joint Pain
Neurological Condition (ALS, Parkinsons, etc)
Chronic Skin Rash
Fibromyalgia
Multiple Sclerosis
Memory Loss / Confusion
Lupus

Other/ Not listed
Cancellation Policies
- No Call/No Show: Failure to cancel or reschedule your appointment at least 4 hours in advance, you will be charged $45 for the therapist time to set up and break down. Payment is due before your next appointment.
- Late Arrival: If you are late to your session you are welcome to receive whatever time is left in your appointment. Due to our tightly booked schedule we are generally unable to extend your session beyond your original appointment time. Regardless of the length of the service actually given, you will be responsible for payment of the full service you scheduled. Please plan to arrive 10 minutes early for your appointment.
Fragrance-Free Policy

Please refrain from wearing perfume, cologne, after-shave, scented lotions, body sprays or other similar "smelly" products on the day if your massage.

Synthetic chemicals found in scented products can trigger migraines and asthma attacks in our sensitive clients.
Smoke-Free Policy

Smokers are asked to please shower before your appointment and avoid smoking until after your appointment; this helps us avoid the smell of smoke in our office, which triggers migraines and asthma attacks in our most sensitive clients, especially children.
Good Hurt vs. Bad Hurt

When you get a massage, you may experience "good hurt" and "bad hurt." It is important to understand the difference between "good hurt" and "bad hurt" because "bad hurt" needs to be avoided.

"Bad hurt" is when you....
- tense up
- wince in pain
- hold your breath
- cringe
- have the feeling you are trying to "push through" the pain.
Bad Hurt will actually cause your whole body to be tense and when your body is tense, the adhesions will not release. To have the best massage results, avoid "bad hurt" by telling your massage therapist right away, as soon as you feel the "bad hurt."
Video Concent

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Nicholas Peltier (Nyx Healing hands) , its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to: Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice. Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in mailings for educational and awareness. This consent is given in perpetuity, and does not require prior approval by me.
Special Consent for Massage of

Inner Thighs, Gluteal (Buttocks),& Pectoral Muscles

What are these areas?
- Inner thighs: adductor muscles
- Buttocks: gluteal muscles, piriformis, sacrum, ischialischial tuberosities
- Pectoral: pectoralis major, pectoralis minor, and intercostal muscles in the chest region.
Even if you consent to massage in this area today, you can always choose not to receive it at any point of your treatment. You, the client, have the right to change consent at any time during a treatment.

The anal area, nipples, and the genitals will always be draped (covered) and will not be touched.

Please let your therapist know immediately if at any time treatment feels uncomfortable in any way.
I consent to my inner thigh being touched during the massage treatment.I consent to my gluteal regions being touched during the massage treatment.I consent to my pectoral regions being touched during the massage treatment.I prefer not to be touched on my inner thighs, gluteals, or pictorial muscles.
Sickness Policy

Please reschedule your appointment as soon as you are aware of an infectious or contagious condition.

If you arrive for your appointment with symptoms of an illness, you will kindly be asked to reschedule your appointment to avoid the spread of germs. This protects our most susceptible loved ones - children, the elderly, & people with suppressed immune systems, like cancer patients.

If any of the following describes you, I kindly ask that you reschedule your appointment so we can prevent the spread of bugs:
- Fever or Chills
- Vomiting or Diarrhea
- Runny Nose
- Sore Throat or Cough
- You are currently taking an antibiotic.
- You have a skin infection like ringworm or athletes foot.
- You or someone in your direct care has a cold, sinus infection, or flu bug.
- You or someone in your direct care has been diagnosed with influenza (the flu).
Even if you are cancelling your appointment within the 24-hour notice period, the cancellation fee may be waived; the onset of symptoms doesn't always have great timing, right?
I agree to the Sickness Policy. I understand that if I show signs of illness I will be asked to reschedule my appointment.

I agree

Covid-19 questionnaire

	I AGREE
My temperature has not been above 98.6°F in the past 72 hrs.
I have not knowingly been in contact with anyone diagnosed with Covid-19 in the past 2 weeks.
I have not had any of the following symptoms in the past 2 weeks: Fever, Cough, Shortness of Breath, Persistent Chest Pain or Pressure.
In the event I contract Covid-19, I will notify my therapist as soon as possible.

Have you been fully vaccinated for Covid-19?

VaccinatedNot vaccinatedVaccinated & booster
By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read the New Client Intake Form in its entirety.

2. I fully understand all questions and information provided in the New Client Intake Form.

3. I have completed the New Client Intake Form accurately and to the best of my knowledge.
Type Full Name:

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Client Intake Form

By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read the New Client Intake Form in its entirety.

3. I have completed the New Client Intake Form accurately and to the best of my knowledge.