New Client Form 1Personal Information2Medical Information3Massage Information4General Liability5Cancellations & Behavior6COVID19 Please complete this form prior to your first appointment.Name* First Last Phone*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Occupation Employer Primary Physician Emergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Email How did you hear about us?* Are you taking any medications?* Yes No List medications.* Are you currently pregnant?* Yes No How many weeks?*Please enter a number from 0 to 100.Any high risk factors?* Do you suffer from chronic pain?* Yes No Please explain the location and cause of your pain.*What makes your pain better?* What makes your pain worse?* Have you had any orthopedic injuries?* Yes No List injuries.* Please indicate any of the following conditions that apply to you.* Cancer Headaches/Migraines Arthritis Diabetes Joint Replacement(s) High/Low Blood Pressure Neuropathy Fibromyalgia Stroke Heart Attack Kidney Dysfunction Blood Clots Numbness Sprains or Strains None of the Above Explain any conditions you have marked above.* Have you had a professional massage before?* Yes No What type of massage are you seeking?* Relaxation Therapeutic/Deep Tissue What pressure do you prefer?* Light Medium Deep Do you have any allergies or sensitivities?* Yes No Please explain any allergies or sensitivities.* Are there any areas (face, feet, abdomen, etc) you do not want massaged?* Yes No List any areas you do no want massaged.* What are your goals for this treatment session?* Massage Intake Consent*By selecting "I accept" below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. I accept General Liability Release Consent*By selecting "I accept" below, you agree to the following: 1. I give my permission to receive massage therapy. 2. I understand that therapeutic massage is not a substitute for traditional medical treatment or medications. 3. I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications. 4. I have clearance from my physician to receive massage therapy. 5a. I understand the risks associated with massage therapy include, but are not limited to: o Superficial bruising o Short-term muscle soreness o Exacerbation of undiscovered injury 5b. I therefore release the company and the individual massage therapist from all liability concerning these injuries that may occur during the massage session. 6. I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition. 7. I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly. 8. I understand that I or the massage therapist may terminate the session at any time. 9. I have been given a chance to ask questions about the massage therapy session and my questions have been answered. I accept Cancellation, Late Arrival and Inappropriate Behavior Policies*We appreciate that you’ve chosen us for your massage and bodywork needs. To provide the best service possible to our clients we have implemented the following policies. 1. Cancellation Policy We respectfully ask that you provide us with a 24 hour notice of any schedule changes or cancellation requests. Please understand that when you cancel or miss your appointment without providing a 24 hour notice we are often unable to fill that appointment time. This is an inconvenience to your therapist and also means our other clients miss the chance to receive services they need. For this reason, you will be charged 50% of the service fee for the first missed session and 100% of the service fee for each session after that. We also reserve the right to require a credit card number to be given to book future appointments so that appropriate fees may be charged if a late cancellation does occur. We understand that emergencies can arise and illnesses do occur at inopportune times. If you have a fever, a known infection, or have experienced vomiting or diarrhea within 24 hours prior to your appointment time, we request that you cancel your session. Inclement weather may also result in the need for late cancellations. We will do our best to give advanced notice if we are closing or need to cancel due to bad weather and we ask you to do the same. Please do not risk your own safety trying to make your appointment. Late cancellation due to emergency, illness, or inclement weather will generally not result in any missed session charges, but this is determined on a case-by-case basis. 2. Late Arrival Policy We request that you arrive 5-10 minutes prior to your appointment time to allow time to fill out any required paperwork as well as answer any intake questions your therapist may have. We understand that issues can arise that may cause you to be late for your appointment. However, we ask that you call to inform us if this ever occurs so we can do our best to accommodate you. Appointment times are reserved for each client, so oftentimes we cannot exceed that reserved time without making the next client late. For this reason, arriving after your appointment time may result in loss of time from your massage so that your session ends at the scheduled time. Full service fees will be charged even when sessions are shortened due to late arrival. In return we will do our best to be on time, and if we are unable to do so we will add time to your session to make up for our late arrival or adjust the service charge accordingly. 3. Inappropriate Behavior Policy Massage therapy is for relaxation and therapeutic purposes only. There is absolutely no sexual component to massage whatsoever. Any insinuation, joke, gesture, conversation, or request otherwise will result in immediate termination of your session and a refusal of any and all services in the future. You will be charged the full service fee regardless of the length of your session. Depending on the behavior exhibited we may also file a report with the local authorities if necessary. Treat your therapist with respect and dignity and you will be treated the same in return. By selecting "I accept", you agree to abide by these policies. I accept Have you received the COVID-19 vaccination?* Yes No (Optional) Attach COVID-19 vaccination proof (pdf, jpg, or png only)Accepted file types: pdf, jpg, png, Max. file size: 4 MB.Precautionary Coronavirus Liability Release Form*Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please review and accept, below. Symptoms of COVID-19 include: • Fever • Fatigue • Dry cough • Difficulty breathing • Chills • Nausea or vomiting • Diarrhea • Confusion • New widespread muscle pain • Headaches • Fatigue • Loss of taste & smell • Bruising, redness, swelling, or cramping in lower legs and feet • Red or purple toes By selecting “I accept”, I indicate that I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. I affirm that I, as well as all household members, have not been diagnosed with COVID- 19 within the last 30 days. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days. I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days. I understand that this business and my massage therapist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client. By selecting “I accept”, I agree to each above statement and release the massage therapist and business from any and all liability for the unintentional exposure or harm due to COVID-19. Your massage therapist and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions. I acceptEmailThis field is for validation purposes and should be left unchanged.