December 30, 2019

New Client Intake Form

CONFIDENTIAL NEW CLIENT INTAKE FORM

NAME:____________________________________________________DOB:____/____/____________________________________________

ADDRESS: ___________________________________________________________________________________________________________

CITY: ________________________________________________STATE:________________________ ZIP: ____________________________

PHONE: (HOME) ______________________________________ (WORK) ____________________________________________________

DO YOU WEAR CONTACT LENSES:_________________ HEARING AIDS__________________ DENTURES _____________

LIST ANY SURGERIES OR INJURIES AND THE APPROXIMATE DATE:

ARE YOU ALLERGIC TO ANYTHING?___________________________

(FEMALES ONLY) ARE YOU OR COULD YOU BE PREGNANT AT THIS TIME? 

Y/N____________________________________________

ARE YOU CURRENTLY OR HAVE YOU EVER EXPERIENCED THE FOLLOWING HEALTH CONDITIONS:

ASTHMA ________________________CANCER ______________________________DIABETES ____________________________

VARICOSE VEINS ________________ PHLEBITIS ____________________________ BLOOD CLOTS _____________________

SKIN CONDITIONS _______________ SEIZURES __________________ HEADACHES _______ HOW OFTEN? ________

ARTHRITIS _____________________ FIBROMYALGIA__________________________ DISLOCATIONS ___________________

HIGH OR LOW BLOOD PRESSURE _________Prescription?__________ HEART CONDITIONS ___________________

DO YOU HAVE ANY COMMUNICABLE OR CONTAGIOUS CONDITIONS?

CoVID-19 : Have you had this disease? __________  Been tested?  ________ Could you have this disease?_________

EMERGENCY CONTACT: ________________________ PHONE # ________________________

To the best of my knowledge, the information given is complete and accurate.  I understand that my massage

therapist cannot prescribe any medications, diagnose or treat any medical conditions.

MISCONDUCT: I also understand that this is a professional establishment and that any situation that

causes discomfort to the massage therapist will be reason for termination of services given.

Signature: ____________________________________ Date: ________________Driver’s License # __________________________

BE IN THE KNOW

Jot down your info and we’ll keep you updated on everything happening On The River (if you haven’t been

receiving our emails/newsletters please sign up again)

EMAIL ADDRESS: ______________________________________________________________ PHONE #_______________________

HOW DID YOU HEAR ABOUT ME? _______________________________________________________________________________