Name:_______________________________Birthdate:_______________________
Address: ________________________________City:_________________________ Apt: ___________ State: _______________ Zipcode: ________________ Phone: (H) ____________________________Work:_______________________ Cell:____________________ Please list your email address if you would like to receive email appointment reminders or the quarterly newsletter:______________________________________ When was your last massage? _____________How often do you have a massage? ______________________ How much water do you drink daily? Reason for today’s visit:___________________________________________ List any accidents, fractures, and surgeries in the past 2 years: How often & what type of exercise do you do?_________________________ Describe any current or ongoing musculoskeletal pain or stiffness & current medications: Are you pregnant? (No) ______ (Yes) ________Due date: ________________ Allergies to any oils, lotions,scents? (No) __________ (Yes) ___________________ If yes, please list: ______________________________________________________ Please list any pertinent medical history:
Please list anything that you strongly like or dislike during your massage session:
__Initials
This information and our sessions are treated with confidentiality. Please give feedback at any time during or after the massage. This communication between you and I during the massage will facilitate a more productive outcome from the session for you.
I, the client, understand that the work done during this massage does not constitute medical treatment and that the massage therapist is not a physician. The session is a form of health and wellness maintenance utilizing the techniques of massage and holistic healing, I, the client, take responsibility for alerting the therapist to any conditions that might affect this work. It is recommended that I, the client, see a physician for any ailments I might have. Any suggestions made by the massage therapist are recommendations not prescriptions.
Cancellation Policy: Failure to cancel an appointment 24 hours in advance and missed appointments are subject to a $65 no show fee. $25 returned check fee
My signature below indicates that I understand and agree to the above conditions.
Signature: ________________________________________Date:__________________________
