Phone *You will receive a text message reminder before your appointment
Email *New Client Intake FormAddress *
Interested in receiving special offers, click yes to be placed on our e-mail list yesno
Date of Birth
Emergency Contact, please include phone number
Date of Intial Visit
Who may I thank for referring you:
Have you had a professional massage before? yesno
Do you have any issues with lying on your front, back or sides? yesno
Do you have sensitive skin including allergies to oils, lotion? yesno
Are you wearing contact lenses? yesno
Do you sit for long hours at work, computer or driving ? yesno
Perform any repetitive movements at work or sports ? yesno
Experience strees in your work, family, or other areas ? yesno
If yes how do you think it has affected your health ?
Is there a particular area of of the body where you are experiencing tension, stiffness, pain or stiffness. If so please explain.
Are you currently under medical supervision? yesno
If yes please explain.
Do you see a Chiroractor ? yesno
If yes, how often.
Name and phone of Chiropractor
Are you taking any medications ? yesno
If yes, please list.
Please check any medical issues you currently are experiencing
fever or flu like systems
contagious skin conditions
open scores or wounds
high or low blood pressure
headaches / migraines
back or neck problems
carpal tunnel syndrome
Please explain any issues you have checked.
Any other information about your health history that you think would be useful for your massage practitioner to know in order to plan a safe and effective massage session for you. yesno
If yes, please explain.
Interested in receiving special offers, click yes to be placed on our e-mail list yesnoStatementI understand that the massage I receive is provided for the basic purpose of relaxing and relief of muscular tension or spasm. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and or strokes may be changed to my level of comfort. I further understand that massage should not be constructed as a substitute for medical examination, diagnosis, or treatment and that I should seek a physician, chiropractor, or other medical qualified specialist for any medical or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and understand that nothing said in the course of this session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I not do so.
Anyone who either forgets or chooses to forgo their first appointment will be considered a “no-show” and will be charged for the full amount of the missed appointment.
No refunds will be allowed.
This office has a zero tolerance policy for any inappropriate behavior, action or language by any client. Doing so will result in immediate termination of the session by the massage therapist.
By checking you are agreeing with this policy. *
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