New Client Intake

Please Complete & Submit Form Below After First Booking

First name*

Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Under the age of 18?*

Yes

If under the age of 18, parent/guardian must be on site either in the lobby or in the treatment room. If yes, parent/guardian name here:

Gender:*

Occupation:*

Referred by:

Primary Reason for Visit:*

Currently or in the past have you been seen by any other care providers for these issues? If yes, please list all care providers:*

Please list any medical conditions:*

Please list current medications:*

Please list any known allergies:*

If I experience pain or discomfort during the session, I will inform my therapist so the pressure/strokes can be adjusted to my comfort level.*

Yes

I understand the services offered today are not a substitute for medical care. I understand my massage therapist is not qualified to perform high velocity adjustments, diagnose, or prescribe.*

Yes

I affirm I have notified my therapist of all known medical conditions and injuries.*

Yes

If any changes in my health and/or medical conditions occur, I agree to inform my massage therapist. I understand there shall be no liability on the therapist's part should I forget to do so.*

Yes

I understand the massage therapy treatment or other services offered are entirely therapeutic and non-sexual in nature.*

Yes

By signing this form, I voluntarily request and consent to receiving massage therapy. *

Signature field is empty.

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