New Client Intake Form

Thank you for your interest. The New Client Intake Form below MUST be completed and submitted before scheduling your first appointment. Any and all information provided on this form or verbally within sessions is held in the strictest of confidence and will not be shared with anyone or any organization. DO NOT use this form to make inquiries. If you have a question, please contact me through other means.

New Client Information:

First Name

Last Name

E-mail

Please describe yourself (information allows me to adjust the table appropriately prior to arrival):

Age

Gender

Male Female

Height

Weight

I would like the following pressure:

Not Sure
Light
Medium
Heavy (Note: Only provided in Therapeutic Massage and Sports Massage)

I like my face massaged (Note: Not offered in all modalities):

Not sure
Yes
No

I experience a massage by a massage therapist:

I have never experienced a massage
A few times a year
About once a month
Once a week or more

Please select all that applies to you:

I am allergic to corn starch and/or peanuts
I have other allergies
I have skin irritations
I have arthritis and/or joint disorders
I have high blood pressure and/or heart problems
I have varicose veins and/or blood clots
I have spinal problems
I have frequent headaches
I am currently under a doctor's care
I am pregnant
I have had recent injuries and/or broken bones
I have had recent surgery

Do you smoke?

No
Yes

Do you drink alcohol?

List any medical condition(s) I should be aware of prior to the session:

If you participate in any sports, please indicate which sport(s) and your level of involvement:

Areas of complaint, pain, and/or tension:

What do you do for a living?

What do you do to develop yourself spiritually (optional)?

How do you hope to benefit from my service?

I would like my breasts massaged (Females only; Note: breasts will not be massaged unless you specifically request this service):

Not sure/I will decide later
Yes
No

I would like the following type of draping to be used:

Not sure/I will decide later
No Draping
Small Hand Towel
Large Bath Towel
Full Sheet

I will pay by:

Cash
Credit Card
Gift Certificate

I found you by (select all options that apply):

Personal Referral
Search on Yahoo
Search on Google
Search on MSN
Search on Bing
Link Found on Another Website
Other

AGREEMENT: By submitting this form, I agree and acknowledge with my electronic signature the following:

I am subject to a 50% fee if I cancel or reschedule within 8 hours of the scheduled appointment.

I am subject to a 100% fee if I do not show up to my scheduled appointment.

I understand the type of massage techniques to be used during the massage therapy session(s) I request.

I understand the parts of my body that will be massaged and/or the areas of my body that will be avoided during the session, including indications and contraindications.

If I am uncomfortable for any reason, I may ask for the massage to cease and Brad will end the massage immediately.

I may choose to be draped or not to be draped. Draping is optional, but not required.

I will turn off all electronic devices while in the studio. I will make Brad aware of any and all electronic devices.

I have listed all of my medical conditions on this form and will update Brad should any new conditions arise prior to this session or any future session(s).

Yes
No