New Client Intake Form

New Clients: Please fill out our electronic intake form prior to your appointment and click submit when complete. Thank you!

BODY RHYTHMS MASSAGE

New Client Intake Form

Full Name

Address/City/State/Zip Code

Cell Phone

Email

Date of Birth

Occupation

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

Are you currently taking any medications? If yes, please list name and use:

Are you currently pregnant? If yes, how far along? Any risk factors?

Do you suffer from chronic pain? If yes, what makes it better? What makes it worse?

Have you had any orthopedic injuries? If yes, please list:

Explain any conditions you have marked above:

Are there any other conditions that are not listed above?

Have you had a professional massage before?

Yes

No

Do you have any allergies or sensitivities, if so please list:

What are your goals for this treatment session?

I have read the Body Rhythms Massage Client Bill of Rights (below) and I understand I have full opportunity to ask any questions I have about this document and my rights as a client. With some medical conditions or symptoms certain treatments are contraindicated. I affirm that I have stated all of my known medical conditions. I agree to keep Body Rhythms Massage updated of any changes in my medical profile and understand that there shall be no liability 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 payment of the scheduled appointment. I understand that massage therapy given here is for the purpose of stress reduction, relief from muscular tension or spasm, and for increasing circulation and energy flow. Massage/Bodywork should not be performed if you have certain medical conditions or specific symptoms. A referral from your primary care provider may be required prior to service being provided. If I experience any pain or discomfort during this session, I will immediately inform the therapist 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 or other qualified medical specialist for any mental and physical ailment I am aware of. 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.

Your Signature

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