Home
About
About Energy Body Mind
Policies
Client Forms
Services/Rates
Massage Therapy
Energy Methods
Schedule/Contact
Massage Client Intake Form
Please use this form if you have an appointment with Energy Body Mind.
FILL OUT BOTH PAGES AND HIT "SUBMIT" AT THE BOTTOM OF EACH PAGE FOR FORMS TO BE VALID
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Date of Birth
*
Occupation
*
Emergency Contact Name
*
First
Last
In the event an emergency should occur, it's important we have someone to contact.
Emergency Contact Phone Number
*
How did you hear about us?
*
Referral
Online
If referral, who?
*
We appreciate your business, and would like to thank who referred you.
Have you received a massage before?
*
Yes
No
What is your main reason for receiving massage?
*
Pain relief
Relaxation
Muscle soreness
Increase energy and rejuvenation
Comments: areas of focus, music preference etc.
*
HEALTH INFORMATION
Please select your overall stress levels
*
High, I'm always on the go
Moderate, It varies
Low, very little stress in my life now
Please select your overall energy levels
*
My energy is pretty consistent
My energy is all over the place
My energy fluctuates
My energy is sluggish most of the time
What are your main stressors in your life at the moment?
*
Please select if any apply to you
*
High Blood Pressure
Low Blood Pressure
Neither
Are you taking any blood pressure medications?
*
Yes
No
Are you pregnant? If yes, how far?
*
Do you experience headaches or migranes?
*
Yes
Sometimes
No
Do you have arthritis?
*
Yes
No
Do you experience any swelling in the tissues?
*
Yes, after sitting long periods
After strenous activity
In the abdomen
No swelling
Do you wear contact lenses or dentures?
*
Yes dentures
yes contact lenses
No
Do you have osteoperosis or joint issues?
*
Yes
No
Do you have allergies or prone to congestion?
*
Yes
No
If you have any allergies, please list them here
*
Do you have any cardiac or circulatory conditions?
*
Yes
No
Do you suffer from epilepsy or seizures?
*
Yes
No
Do you experience any numbness or stabbing pains?
*
Yes, sleeping at night
Yes, during the day
No
Do you bruise easily?
*
Yes
No
Have you suffered an injury or fall in the last 6 months?
*
Yes
No
If you suffered an injury or fall, please specify here
*
Please list any medications (or pain medications) you are currently taking
*
Please describe any other conditions we should be aware of.
*
Are you currently under a Physican's care?
*
Yes, just regular GP
Yes, for specific conditions
No
INFORMED CONSENT TO RECEIVE MASSAGE
I understand that the service I receive is provided for the basic purpose of relaxation, relief of muscular tension, to increase my awareness, and to support my health. If I experience pain or discomfort during the session, I will immediately inform the therapist so that any adjustments can be made to my level of comfort. I further understand that the modalities provided are not a substitute for medical examination, diagnosis or treatment and that the therapist is not qualified to perform any skeletal adjustments. The therapist is not qualified to prescribe or treat any physical or mental illness, and that nothing said in the course of this session should be construed as such. If issues arise apart from this scope, a referral of alternative methods to support your health may be encouraged. Because modalities should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated to any medical changes during the session and understand that there shall be no liability on the therapist’s part should I fail to do so. I also understand that the therapist reserves the right to refuse or perform massage on anyone whom she deems to have a condition for which massage is contraindicated.
Signature
*
First
Last
Submit
POLICIES
Please read and sign below.
CANCELLATION POLICY
Any cancelled/rescheduled appointments within 48 hours of your appointment start time will be charged 50% of the service total cost.
Day-of cancellations will be charged 100% of the scheduled services.
CREDIT CARD POLICY- PAYMENT METHODS
All clients will be required to have an active card on file.
Clients who remove their cards linked to their profile will be contacted to add another card on file. If contact is unable to be made, any outstanding appointments will be canceled.
If client prefers not to use a card, Zelle contact information is required to keep on file.
CASH POLICY
5% discount will be applied for clients paying cash.
ADDITIONAL MILEAGE FEE
Therapist’s travel outside of 20 miles from Chino Valley will incur a $20 fee.
CHILDREN/PET POLICY
For the safety of your children and pets, and for your relaxation, it is encouraged to keep them outside the treatment space.
CELL PHONES POLICY
Please silence all cellular devices and refrain from taking phone calls during your session.
NO-POLITICS POLICY
All services aim to create a calm and relaxing atmosphere. To support a peaceful environment, please keep all political conversations outside the treatments space.
Thank you for understanding and supporting a stress-free experience.
In order to accommodate all clients, these policies will be strictly enforced.
I have read and agree to these terms and policies
*
Check here
*
Indicates required field
Signature
*
First
Last
Submit
Home
About
About Energy Body Mind
Policies
Client Forms
Services/Rates
Massage Therapy
Energy Methods
Schedule/Contact
