CLIENT CONTACT INFORMATION

Name

First Name

Last Name

Date of Birth

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Preferred Method of Contact

Referred By

Emergency Contact

Please include Name & Relation

Emergency Contact Number

MASSAGE INFORMATION

Have you ever received professional bodywork/massage before?

Yes

How recently?

What types of massage/bodywork do you prefer?

What kind of pressure do you prefer?

Light

Medium

Firm

What are your goals/expected outcomes for receiving massage/bodywork?

How do you feel today?

List and prioritize your current symptoms/issues

(stress, pain, stiffness, numbness/tingling, swelling, etc)

Do these symptoms interfere with your activities of daily living?

(sleep, exercise, work, childcare, etc)

Yes

If yes, explain.

HEALTH HISTORY

List the medications you currently take

Are you wearing contacts?

Yes

Are you pregnant?

Yes

Have you had any injuries/surgeries in the past that may influence today's treatment?

Yes

Please check any of the following health conditions that you currently have

If unsure, please ask Please answer honestly as massage may not be indicated for the following conditions.

Blood Clots

Infections

Congestive Heart Failure

Contagious Diseases

Pitted Edema

Describe in detail all conditions indicated

Comments

Anything else you want us to know prior to treatment

COVID SCREENING

Have you been in contact with any confirmed Covid-19 positive patients or the flu? Or in contact with anyone currently awaiting results?

Yes

If yes, when?

COVID WAIVER

I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 14 days. By signing below I agree to each above statement and release the massage therapist and business from any and all liability for the unintentional exposure or harm due to COVID-19 I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage and bodywork from this practitioner.

I have read and agree to the COVID waiver, understand the risks involved, and release Massage by Priscilla LLC from any and liability in the event I should contract the virus.

Electronic Signature

By typing your name here, you are attesting that the information you have provided is accurate to the best of your knowledge and that you consent to treatment provided by Massage by Priscilla LLC.

First Name

Last Name

Today's Date

OFFICE POLICY

Please be advised of the policies for this office. Your signature below signifies acceptance of these policies. Cancellation A 24-hour notice is required for cancellation of an appointment, or you will be charged in full for the appointment. Payment is due before your next appointment. Tardiness Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. Please be on time to your appointment. Sickness Massage bodywork is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived. Your signature below confirms your financial responsibility for all services provided by this office.

I have read & agree to the terms of the office cancellation policy established by Massage by Priscilla LLC

CONSENT TO TREATMENT

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

I have read & agree to the consent to treatment as established by Massage by Priscilla LLC

Electronic Signature

By typing your name here, you are attesting that the information you have provided is accurate to the best of your knowledge and that you consent to treatment provided by Massage by Priscilla LLC.

First Name

Last Name

Today's Date

New client intake form