New client intake form

CLIENT CONTACT INFORMATION
Name *
Name
Address *
Address
Phone *
Phone
Please include Name & Relation
include phone #
Is this Massage/Bodywork medically necessary? *
Do you have a physician referral/prescription? *
MASSAGE INFORMATION
Have you ever received professional bodywork/massage before? *
What kind of pressure do you prefer? *
(stress, pain, stiffness, numbness/tingling, swelling, etc)
Do these symptoms interfere with your activities of daily living? *
(sleep, exercise, work, childcare, etc)
HEALTH HISTORY
Are you wearing contacts? *
Are you wearing dentures? *
Are you wearing a hairpiece? *
Are you pregnant? *
Have you had any injuries/surgeries in the past that may influence today's treatment? *
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.
Please indicate conditions that you have or have had in the past *
Describe in detail below, including all treatment received. Or check none of the above
Anything else you want us to know prior to treatment
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.
*
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.
*
Electronic Signature *
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.