Caron Massage Client Intake Form

Client Intake Form

About you...

All information is confidential.
Name: *

First Name Middle Name Last Name
Birth Date: *

Month Day Year
Gender: *
Phone: *

Area Code Phone Number
This is my: *
E-mail: *
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Occupation: *
How did you hear about me? *
Have you had a massage before? *

Yes No
If Yes, how long ago?
Please describe any issues you've currently been experiencing with your body and how you'd like your therapist to help you with those areas. *
Any particular area(s) to focus on? *
Please Check all Areas you are feeling discomfort. *

Head/Scalp Neck Shoulders Arms/Hands/Wrist Upper Back Mid Back Low-Back Glutes Hips Hamstrings Quadriceps Calves Ankles/Feet
Are you currently under the care of a physician, chiropractor, psychologist, or physical therapist for an ongoing condition or problem? *
Have you had any major surgical procedure? *
If yes, briefly explain:
Is your condition related to an accident or injury? *
If Yes, describe accident and approximate date
Are you taking any medications presently? *
If yes, please list medication(s)
Are you currently experiencing symptoms of any of the following conditions? If you currently are ill your session MUST be rescheduled for 48 hours after symptoms subsides.
Please check all that apply: *

Not currently ill Cold Flu Fever Infection Skin Rash Anything Contagious
Certain medical conditions or symptoms may be aggravated or get worse by receiving a massage. A referral from your primary care provider may be requested before your session. You are encouraged to check with your doctor to be sure massage therapy is appropriate for you. This includes musculoskeletal, circulatory, respiratory and skin conditions. If your condition is not below please mark other and advise.
Please check all that apply: *

No health Issues Diabetes Cancer Stroke Surgery Joint Ache Pregnant Seizures Whiplash Headaches Depression Anxiety/Panic Attacks Skin Conditions Heart Condition Broken Bone Dislocated Bone Blood Pressure Slipped Disk Herniated Disk Auto-Immune Disease Hepatitis A,B,C other Arthritis Tree Nut Allergy Other Allergies Varicose veins Blood clots Asthma Sinus Issues Open Wound/Sore Fungal infections TMJ disorder Athlete's Foot Scoliosis Breast Augmentation
The following sometimes occurs during massage.
They are normal responses to relaxation.
Trust your body to express what it needs to:
need to move or change position - sighing, yawning, change in breathing, stomach gurgling - emotional feelings and/or expression,movement of intestinal gas, energy shifts - falling asleep, memories

Client Agreement:

1. I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and treatment.

2. This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.

3. I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my Massage Therapist so they can adjust the pressure to my comfort. I have informed my Massage Therapist of all known medical conditions and understand it is my responsibility to keep my Massage Therapist updated on my physical health. I understand that my failure to do so may pose a threat to my health and/or physical well being and I hold harmless my Massage Therapist from any liability whatsoever arising from failure on my part.

Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please reschedule your session if you are more than 15 minutes late

• 24 hour cancellation notice is requested to avoid being charged for your session

By Hitting the SUBMIT button below, I agree to the massage policy and client agreement above.
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