Gift Certificates

Intake Form

Client Intake Form

 

Name *
Name
Address
Address
Phone
Phone
Preferred Method of Contact: *
Can we contact your referral above to thank them?
About You
Fill out the questions below so we can best help address your needs during your visit.
Date of Birth
Date of Birth
Have you had a professional massage before? *
Do you have difficulty lying on your front, back or side?
Do you have any allergies to oils, lotions, or herbs?
Do you spend more than 2 hours a day standing, in seated posture, or in repetitive motions, whether it be work related or otherwise?
Has your stress or work level changed in the last 6 months?
If yes, have you noticed an increase of any of the following:
What are your goals for today’s session?
Medical History
In order to plan a massage session that is safe and effective, I need some general information about your medical history. Please answer the following as accurately as possible.
Are you currently under medical supervision?
Do you see a Chiropractor often?
Are you currently taking any medications?
Please check any conditions listed below that apply to you:
Draping will be used throughout your entire session, and only the area being worked will be uncovered. Clients under the age of 17 must either be accompanied by a legal guardian, or have an intake form signed by their legal guardian on file. I understand that the massage that I receive is provided by a licensed therapist for the purpose of relaxation and the relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes can be adjusted to my level of comfort. I further understand that massage should not be misconstrued as a substitute for medical examination, diagnosis, or treatment. I also understand that the therapist will only work within his/her scope of practice in manual therapy techniques. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep my therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part if I fail to do so.
Sign below to authorize.
Signature *
Signature