New Client Intake

I will take the time to prepare and research in order to make the most out of our time together. Please submit at least 24 hours prior to your session.

First Name

Last Name

Phone

Address

Birthday required

How did you hear about me?

Have you been hospitalized in the last 12 months?

Yes

Are you currently suffering from a medical condition, illness, injury, or chronic pain?

Yes

If you answered yes to either question, please elaborate:

Are you currently pregnant?

Yes

If yes, what is your due date?

What are your goals and/or intentions for our work together?

What has been your experience with massage and bodywork in the past? What did you like or dislike? What massage modalities are you familar with and/or want?

What types of physical movement and/or positions regularly appears in your work, daily life or recreation?

What substances are you currently taking? (Please include any/all herbs, prescription medications, supplements, recreational drugs, homeopathic remedies)

Are there any aromatherapy fragrances and/or oils that you would not like used? If yes, please list below

Is there anything else you would like me to know for our work together?

Liability and consent waiver:

I affirm that I have notified my massage therapist of all known medical conditions and injuries.
I agree to inform my massage therapist of any changes in my health an medical condition and that there shall be no liability on the therapist's part should I forget to do so.
I understand that massage therapy is not a substitute for medical care, and my massage therapist cannot prescribe, diagnose, or treat mental/physical illnesses.
If I experience pain or discomfort during the session, I will immediately inform the massage therapist so that the massage can be adjusted to my comfort. I will not hold my massage therapist responsible for pain or discomfort I experience during or after the massage.
I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.

I declare that the information I've provided is accurate and complete

Initials

Today's date required