New Client? You’re in the right place

Name (required)

City

State

Email Address

Phone

Referred By

Emergency Contact Information

Occupation

Hobbies

Have you ever had a professional massage before? if so, how often?

How are you feeling today?

Are you, or have you been under the care of a medical doctor, chiropractor, or health care provider? If yes, please explain.

Are you on medications currently? If yes, please list them.

Have you been in an accident or suffered any injuries in the past two years? If yes, please explain.

Do you have any areas of specific pain? If yes, please explain.

Please check any of the following that apply to you

 Anxiety/Depression High Stress Contagious Disease Epilepsy/Seizures Varicose Veins Fibromyalgia High Blood Pressure Pregnant Asthma Cardiac/Circulatory Problems Diabetes Shooting Pain (details in comments) Tingling Fingers or Toes Low Blood Pressure

Any Other conditions we should know about?

Please carefully read the following information and accept the terms where indicated. For some specific symptoms and medical conditions, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.

 I understand that the massage/bodywork I receive is not to be construed as a medical examination, or diagnosis. I understand that massage/bodywork is not to be performed under certain medical conditions. I affirm that I have stated all of 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 if 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 the payment of the scheduled appointment.