Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth (DOB) *

MM

DD

YYYY

Pain Scale (check the one that apply) *

0 (Low)

1

2

3

4

5

6

7

8

9

10 (high)

Stress levels? (check the one that apply) *

0 (Low)

1

2

3

4

5

6

7

8

9

10 (high)

Have you had a professional massage before? *

Yes

No

Do you have any of the issues listed below? (check all that apply) *

High blood pressure

Low blood pressure

Chronic congestive heart failure

Heart attack

Varicose veins

Heart disease

Taking blood thinners

Chronic cough

Shortness of breath

Bronchitis

Asthma

Emphysema

Hepatitis

Tuberculosis

HIV

Skin conditions

Auto Immune conditions

N/A

Do you have cancer? *

Yes

No

Where do you have pain? (check all that apply) *

Headaches/Migraines

Face pain

Neck pain

Upper back

Middle back

Low back

Glutes/Butt

Arms

Legs

Feet

Have you been vaccinated recently? *

Yes

No

Are you doing other forms of manual therapy? *

Yes

No

Are you pregnant? *

Yes

No

Do you have heart arrhythmia? *

Yes

No

Accuracy of Information *

I certify that the above medical information is correct to my knowledge.

Privacy & Sharing *

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with myfamily doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

Cancellation Policy *

*****UNREFUNDABLE***** ****** NON-EXCHANGEABLE****** "Please Note: A 3% processing fee applies to all credit card transactions. There are no fees for payments made via Zelle, Venmo, or Cash App." Cancellation Policy: Our cancellation policy ensures fairness and respect for both our clients and therapists. To cancel an appointment, we require a minimum of 24-hour notice. If canceled within this timeframe, there will be a 50% charge applied. However, if the therapist is already en route to your location or has arrived on the premises, the full charge for the scheduled massage session will be applied. This policy is in place to honor the time and commitment of our therapists, as well as to manage our appointment schedule efficiently. Please note that due to the weight of our massage table, we are unable to navigate stairs. Therefore, we reserve the right to decline massage appointments scheduled in locations requiring staircase access. We apologize for any inconvenience this may cause. We appreciate your understanding and cooperation in adhering to our cancellation policy. Packages can be shared among family members. They are designed for monthly use but must be utilized at least every two months. If not, a $35 fee will be applied per person regularly using the package. Packages are intended for consistent use. If a client falls off routine, they may be asked to pay individually when their package runs out. Packages of 10 are strictly for clients planning a minimum of two massages per month. This option also includes couples planning monthly massages together. Cancellation and Refund Policy: Commitment: Massage packages are a commitment to your body, with the understanding that consistent massage provides the best benefits for recovery. Refunds are not available once a package is purchased. Consistency: By committing to a massage package, you agree that this time is not a luxury but something your body needs. If circumstances change after purchase, you will need to use the package; no refunds will be issued. Cancellation Charges: If you need to cancel a session, the following charges will apply: 50% of the original cost if the cancellation occurs within 24 hours of the appointment. (From Credit Card on File)100% of the original cost if the cancellation occurs while en route or on the premises. If you’re unable to commit to consistency, my hourly rate is more than fair—please consider paying per session instead.

I am aware of the Cancellation Policy.

Time

Hour

Minute

Second

AM PM