INTAKE FORMPlease fill out this form prior to your visit. If you prefer, you can download a PDF and submit via EMAIL, or bring it with you to your appointment. PDF FORM NAME First Name Last Name DATE OF BIRTH ADDRESS Address 1 Address 2 City State/Province Zip/Postal Code Country EMAIL * PHONE (###) ### #### DO YOU HAVE ANY OF THE FOLLOWING? MARK ALL THAT APPLY COLD | FLU | HIGH FEVER | COVID-19 HIGH BLOOD PRESSURE HEART TROUBLE BLOOD CLOTS SPINAL PROBLEMS ALLERGIES OSTEOPOROSIS MIGRAINES VARICOSE VEINS NUMBNESS OR PAIN DIABETES AUTO-IMMUNE DISORDER ANY CONTAGIOUS DISEASE ARTHRITIS CANCER SKIN PROBLEMS RECENT ACCIDENT BRUISE EASILY LATEX ALLERGY NONE OF THE ABOVE IF PREGNANT, LIST DUE DATE: PLEASE EXPLAIN ANY CONDITIONS SELECTED ABOVE: ANY OTHER CONDITIONS YOUR THERAPIST SHOULD BE AWARE OF? CURRENT MEDICATIONS: MASSAGE TYPE (CHOOSE ANY THAT INTEREST YOU): TMJ DISFUNCTION THERAPY PLEASE CLICK YES AFTER READING EACH ITEM BELOW The licensee shall drape the breasts of all female clients and not engage in breast massage of female clients unless the client gives written consent before each session involving breast massage. * YES Draping of the genital area and gluteal cleavage will be used at all times during the session for all clients. * YES The licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature. * YES If the client is uncomfortable for any reason, the client may ask the licensee to end the massage, and the licensee will end the session. The licensee also has a right to end the session if uncomfortable for any reason. * YES I, the undersigned, understand that the massage/bodywork I receive is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. 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 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 am aware that if I have any serious medical diagnosis, I must provide a physician’s written consent prior to services. 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 this is a full draping facility and 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 full payment of the scheduled appointment. * YES SIGNATURE DATE MM DD YYYY Form received — thank you! I will follow up via email with any questions.