Massage by priscilla
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Home
Services
Book Now
About
Contact Us
Massage by priscilla
licensed massage therapist
New client intake form
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
*
(###)
###
####
Email
*
Preferred Method of Contact
Email
Phone
Text
Referred By
Emergency Contact
*
Please include Name & Relation
Emergency Contact Number
*
MASSAGE INFORMATION
Have you ever received professional bodywork/massage before?
*
Yes
No
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
No
If yes, explain.
HEALTH HISTORY
List the medications you currently take
Are you wearing contacts?
*
Yes
No
Are you pregnant?
*
Yes
No
Have you had any injuries/surgeries in the past that may influence today's treatment?
*
Yes
No
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
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
Muscle/Joint Pain
Muscle/Joint Stiffness
Numbness/Tingling
Swelling
Bruise Easily
Sensitive to Touch/Pressure
High/Low Blood Pressure
Stroke/Heart Attack
Varicose Veins
Cancer
Epilepsy/Seizures
Headaches/Migraines
Dizziness/Ringing in the Ears
Digestive Conditions (i.e. Crohn's, IBS)
Arthritis (Rheumatoid/Osteoarthritis)
Osteporosis/Degenerative Spine/Disk
Scoliosis
Broken Bones
Diabetes
Depression/Anxiety
None of the Above
Describe in detail all conditions indicated
Comments
Anything else you want us to know prior to treatment
Have you been in contact with any confirmed Covid-19 positive patients or the flu? Or in contact with anyone currently awaiting results?
*
Yes
No
If yes, when?
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
*
Thank you!
