New Client Form
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Occupation
Referred By
*
Google
Facebook
Instagram
Friend/Family
Other:
If Friend/Family or Other, please name below:
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
General Medical History Information
Have you ever received any kind of bodywork (chiropractic, massage, etc.)
*
Yes
No
If yes, how frequently?
*
List any current medications, along with reason for taking:
*
List any surgeries/hospitalizations, along with aprx. date:
*
List any allergies (medicines, seasonal, etc.):
*
Do you have any of the following?
*
AIDS/HIV
Auto Immune Disorder
Asthma
Blood Clots
Bone/Joint Disorder (Arthritis, Osteoporosis, etc.)
Digestive Issues (IBS, IBS-C, Leaky Gut, etc.)
Headaches/Migraines
High Blood Pressure
Low Blood Pressure
Numbness/tingling/burning
Poor Circulation
Varicose Veins
Other
Daily Water Intake
*
Daily Caffeine Intake
*
Describe Your Diet:
Type & Frequency of Movement:
*
General Lifestyle Information
Type & Frequency of Self Care:
*
Describe your sleep quality:
*
On a scale of 1 to 10, rate your stress level:
*
1=little stress, 10=incredibly stressed
On a scale of 1 to 10, rate your energy level:
*
1=little/no energy, 10=high energy
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Areas of Pain or Concern
Describe your primary areas of pain or concern:
*
How did your symptoms begin; when did they begin?
*
On a scale of 1 to 10, rate your pain/discomfort level:
*
1=little/no pain, 10=unbearable pain
Are you interested in home care suggestions & information (i.e. stretches, self massage techniques, movement modification suggestions, etc.)?
Yes, I am committed to working on my areas of pain/concern at home.
No, I am only interested in receiving massage.
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Therapeutic Massage Waiver Form
Please take a moment to read & digitally initial all of the following statements:
If I experience pain or discomfort of any kind during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort.
I recognize that it is my responsibilty to communicate with my therapist my needs & expectations; I will not hold my therapist responsible for any pain or discomfort during or after the session.
I under stand that the services offered today are intended to be in support of medical care;
I understand the services are
not a subsitute for medical care.
I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, perscribe, or treat physical or mental illness.
I affirm I have notified my therapist of all known medical conditions, injuries (past/present), and surgeries.
I agree to inform my therapist of any changes in my health and medical condition.
I understand that there shall be no liability on my therapist's part should I forget to do so.
I understand that massage is entirely therapeutic and non-sexual in nature.
By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future, relating to massage therapy and bodywork.
CANCELLATION POLICY
I understand that should I cancel an appointment
less than 48 hours before the scheduled time
or "no show" for an appointment, I am subject to a fee equal to the cost of the missed appointment.
If the appointment was booked under a gift certificate, it will be voided in lieu of the fee.
Signature
*
Sign by pressing & holding the cursor.
Date
*
-
Month
-
Day
Year
Date
Submit
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