Aurora Sky Massage: New Client Intake Form NEW

Aurora Sky Massage

5300 Sequioa Rd NW, Suite 104, Albuquerque, NM 87120

505-355-8907 | www.auroraskymassage.com | auroraskymassage@gmail.com
New Client Intake Form
Name *

First Name Last Name
Gender *
Phone Number *

Area Code Phone Number
Email *
Your Birthday *

Month Day Year Date Picker Icon
May we add you to our email list?

Mailing Address

Street Address
Street Address Line 2
City	State
Zip Code	Country

How do you prefer for Aurora Sky Massage to contact you? *
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
How did you hear about me? *

Facebook Instagram Google Search Referral (type name below)
Please Run the Wizard
How often do you like to get a massage/bodywork? *
When was your last massage or bodywork? *
What is more important to you? *
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 would you prefer during your massage session? *
What are your top priorities to be addressed at your appointment? *

Low Back Pain Sciatic Pain Neck Pain Hip Pain Tight Glutes (Butt Muscles) Shoulder Issues Tension Headaches
What are your current issues & how are they affecting you? *
What type of pain are you currently experiencing? *

Stabbing Pain Electrical Pain (Sharp Electric Shock) Burning Pain Achy Pain Widespread Pain & Tenderness Muscle Spasms Tension Pain Sharp Pain, Localized, Small Area None
How did your issue/pain begin? *

Slowly Suddenly It has gotten worse over time. It has improved over time. I'm not sure how it happened or how it progressed. N/A I do not have an issue or pain.
In your entire lifetime, have you ever had any of the following surgeries? *

Any Orthopedic Surgery Carpal Tunnel Surgery Rotator Cuff Surgery Neck / Back Fusion Knee Surgery Hip Replacement Ankle Surgery Gallbladder Surgery Hysterectomy Appendectomy (Appendix Removal) Breast Surgery Lymph Node Removal
Please list all surgeries:
HEAD INJURY: Please list any significant head injuries, like concussions, being knocked unconscious, or traumatic brain injury.
BODY INJURY: Please list any significant injuries to your joints, muscles, or bones.
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 medicine pump)? *
Are you currently pregnant? *
Which prescription medications are you currently taking? *

I am NOT taking any prescription medications. I just take Aspirin for my heart. I take a blood thinner medication.
Medical History: If you have experienced any of the symptoms that is marked with an asterisk (*), please call Kelsey to discuss your medical history before booking an appointment; this is to ensure your safety and well-being.

Medical History *

	Current	Past	Never
Pregnancy*
Blood Clots*
Pacemaker*
Congestive Heart Failure*
Unexplained Calf Pain*
Varicose Veins*
Stroke or Heart Attack*
Cancer*
Car Accident*
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
Chronic Pain
Chronic Numbness / Tingling
Neurological Condition (ALS, Parkinsons, etc)
Chronic Skin Rash
Highly Sensitive to Certain Smells or Fragrances
Fibromyalgia
Multiple Sclerosis
Memory Loss / Confusion

Cancellation Policies

100% Full Payment is required for the following conditions:
- No Show : If you do not show up for an appointment, you will be charged the full cost for the appointment. Payment is due before your next appointment.
- Groupon Client(s) , if you no-show for an appointment or do not cancel within our 24-hour policy, we reserve the right to redeem your voucher without your permission and you will lose your voucher.
- 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 10-15 minutes early for your appointment for your required health intake form.
50% Payment is required for the following condition:
- Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 50% of the scheduled appointment fee. Payment is due before your next appointment.
Fragrance-Free Policy

Aurora Sky Massage asks for all clients to refrain from wearing perfume, cologne, after-shave, scented lotions, body sprays or other similar "smelly" products on the day you visit Aurora Sky 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 muscle knots 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."
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 are 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?
Special Consent for Massage of Chest Region

Treatment of certain chest, neck, and back issues will be most effective when it is preceded by the relaxation of surrounding muscles, which includes the pectoralis major, pectoralis minor, and intercostal muscles in the chest region.

In order to achieve treatment goals, your therapist may deem it appropriate to work on muscle or connective tissue near or underneath breast/chest tissue. Your therapist will do their best to avoid breast tissue and minimize pressure.

Even if you consent to breast massage today you can choose not to receive it at any point of your treatment or limit the massage. You, the client, have the right to change consent at any time during a treatment .Please let your therapist know immediately if at any time treatment feels uncomfortable in any way.
Consent for Massage of Chest Region *
Special Consent for Massage of Inner Thighs, Gluteal Muscles (Buttocks), & Pelvic Floor

What are these areas?
- Inner thighs: adductor muscles
- Buttocks: gluteal muscles, piriformis, upper and lateral sacrum
- Pelvic floor: ischial tuberosity, sacrotuberous ligament, coccyx, lower sacrum
Why work these areas?

Many times, pain or discomfort in the lower back is due to issues with the muscles in the buttocks, inner thigh, and pelvic floor regions.

Client Education = Empowerment

In order to achieve treatment goals, your therapist may deem it appropriate to work on muscle or connective tissue in the inner thighs, buttocks, and pelvic floor regions.

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

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.

Please let your therapist know immediately if at any time treatment feels uncomfortable in any way.
Consent for Massage of Inner Thighs, Gluteals, & Pelvic Floor Region *
Informed Consent
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 for Aurora Sky Massage LLC in its entirety.

2. I fully understand all questions and information provided in the New Client Intake Form for Aurora Sky Massage LLC.

3. I have completed the New Client Intake Form for Aurora Sky Massage LLC accurately and to the best of my knowledge.

4. Any sexual harassment, innuendo or proposition will not be tolerated and is subject to immediate termination of your appointment and full payment will be enforced. If necessary the appropriate law enforcement will be notified and charges will be filed.
Type Full Name: *

First Name Last Name
Signature *
Today's Date *

Month Day Year Date Picker Icon
Please Run the Wizard
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

New 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 for Aurora Sky Massage LLC in its entirety.

3. I have completed the New Client Intake Form for Aurora Sky Massage LLC accurately and to the best of my knowledge.