Client Intake Form

    Please complete your intake form so I can better serve you

    Client Intake Form

    Please complete your intake form so I can better serve you

    General Information

    First Name:

    Last Name:

    Email:

    Phone:

    Address:

    Unit/Apt #:

    City:

    State:

    Zip:

    Occupation:



    Date of Birth:


    Have you had a professional massage before: YesNo

    What pressure do you prefer: LightMediumDeepNot Sure

    What is your goal for the treatment?

    Emergency Contact Info

    Emergency Contact:

    Relationship:

    Contact Phone:

    General Medical Information

    Primary Complaint:

    Cause of Complaint (if known):

    Allergies and/or Sensitivities:


    Are you currently pregnant? (if applicable): NoYes, how far along:

    Mark areas of Concern:


    Head & Neck Issues:
    HeadachesJaw Pain or TMJMigrainesHearing LossVision LossSinus Problems
    Other
    Soft Tissue or Joint Dysfunction:
    HeadNeckRight ShoulderLeft ShoulderRight ArmLeft ArmRight ElbowLeft ElbowRight WristLeft WristRight HandLeft HandRight HipLeft HipRight KneeLeft KneeRight LegLeft LegRight AnkleLeft AnkleRight FootLeft FootUpper BackMid-BackLower BackOther
    Pain Sensations:
    BurningNumbnessStabbingTinglingTensionSharpDullThrobbingAchingShockingOther
    Skin Conditions:
    Bruise EasilySkin IrritationsMelanomaEczemaPsoriasisOther
    Infectious Conditions:
    Athlete's FootRingwormMRSARespiratory InfectionHerpesTuberculosis
    Other
    Cardiovascular Issues:
    Blood ClotsAneurysmCold HandsCold FeetPacemakerVaricose VeinsHeart DiseaseOther
    Respiratory Conditions:
    AsthmaChronic CoughBronchitisShortness of BreathEmphysemaOther
    Other Conditions:
    CancerKidney DiseaseMental IllnessEpilepsyInsomniaArthritisDiabetesFibromyalgiaShinglesLupusCerebral PalsySurgical Pins/WireAnxietyDepressionHerniated DiscMultiple SclerosisGoutParkinsons Dis.Alzheimers Dis.Other

    Policies, Consent, and Records Release Authorization

    Payment:

    Payment is due on the same day of the treatment and after the massage session. Cash, check, or credit cards are accepted.

    Cancellations:

    I understand that if I need to cancel an appointment I will give at least 24-hours notice and that any cancellation or missed appointment without a 24-hour notice may result in being billed the full price of treatment to Remedy Massage LLC (extenuating circumstances are considered).

    Lateness:

    I understand that lateness will cut short my massage time and if I am 15 minutes late or more, without proper notice, my massage may be rescheduled.

    Illness:

    I understand that if I am experiencing symptoms of a cold or flu, have had a recent injury or am under a physician's care that I will need to provide the proper paperwork from my health care provider and/or reschedule my massage.

    Confidentiality:

    At this facility, we are committed to protecting your privacy and the confidentiality of your medical records. We are trained and sensitized to the state and federal requirements and are held to the utmost ethical standards to maintain your privacy and information.

    Release of Records:

    Your medical record is the physical property of Remedy Massage LLC: however, the information contained in the record belongs to you and will only be released to other professionals with your written consent. You have the right to review and request a copy of the information used to design and carry out your treatment, ask us to amend the information which you feel is wrong or incorrect, ask us to restrict the information we share about you, ask us to communicate with you in a certain way or place, request a list of who has received your records.

    By voluntarily signing below, I agree to the above terms and conditions. I have read, the above policies, consent, release information and have electronically filled out my intake form with my medical history. I have also had an opportunity to ask any questions before, during, or after my treatment. I intend for this consent form to cover the entire course of treatment for my present condition and for any future condition for which I seek treatment.

    *Client / Patient Signature:



    Minors Only (if client/patient is under 18 years of age):

    I, (parent/legal guardian), give permission for the client or patient mentioned above to receive a professional massage. I have read and am also signing his/her Confidential Case History form and agree to the above terms.

    *Parent / Legal Guardian Signature:

    Submission Date: