Client Intake

Date of appt. * +

First Name *

Last Name *

Date of Birth * +

Gender *

Male

Female

Other Other

Street Number *

Street Name *

City *

State *

Zip Code *

Cell Phone # (or preferred phone) *

Email Address

Confirm Email Address

Would you like to receive text specials? *

Yes

No

Occupation *

Covid - Pre-Session Health Check-in

Please answer a few questions before we proceed:

1: Have you had a fever in the last 24 hours of 100.4*F or above? *

Yes

No

2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat or shortness of breath? *

Yes

No

3. Do you now, or have you recently had any chills, muscle aches, new loss of taste or smell, or new rashes or lesions? *

Yes

No

4. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *

Yes

No

(If the answer is Yes to any of the above questions, we unfortunately will not proceed with the appointment.)

By keeping this massage appointment, you consent to and acknowledge the risks and will not hold us responsible if viral symptoms appear after the session.

*

I understand and agree

The following information will allow your therapist to provide you with the best session possible. This information is strictly confidential to Healing Hands Massage staff. We do not share information with any other outside individuals or companies.

Please share your goals for the session if it is other than relaxation and/or relief from stress or tension.

Do you perform repetitive movements in your work, sports or hobby? *

Yes

No

Do you sit for long hours at a computer or while driving? *

Yes

No

Are you currently experiencing tension, stiffness, discomfort or pain? *

Yes

No

If yes, does it limit your movement in any way? *

Yes

No

Have you been involved in a motor vehicle accident in the past 12 months? *

Yes

No

Have you recently had any injury, surgery or areas of inflammation? *

Yes

No

Do you bruise easily? *

Yes

No

Do you have sensitive skin? *

Yes

No

Are you currently pregnant? *

Yes

No

If yes, how far along is the pregnancy? *

Have you had a professional massage before? *

Yes

No

Health History (pleaase check any conditions you have experienced in the past 12 months or are currently experiencing):

Please use this space to list any other conditions and/or more details on those checked above:

Please list all current medications:

Please list any allergies:

Please list any sports or exercise you participate in regularly:

I understand that any therapy session I receive with Healing Hands Massage, is provided strictly for the basic purpose of relaxation and relief from stress and tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist. I affirm that I have stated all known medical conditions and understand that there shall be no liability on the therapist's part if massage is contraindicated. We suggest a physician's consent if there is any question). I also understand that all therapy sessions are strictly therapeutic and that any illicit or sexually suggestive remarks or advances on my part will result in immediate termination of the session and I will be liable for payment in full. I am aware that I am requred to give a minimum of four (4) hours notice to cancel any appointments, regardless of when they were made. I will be responsible for full payment if failing to do so. Special Note: All massage therapists are under contract with Healing Hands Massage and are not legally permitted to independently massage any Healing Hands Massage client without written consent from one of the owners.

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Date of signature * +