NEW Client intake formPlease fill this form out prior to the arrival of your first appointment. Name * First Name Last Name Email * Phone (###) ### #### How did you hear about us? * Have you suffered any serious injuries. If yes, please explain: Why are you seeking massage therapy? What areas would you like to focus on? Slect all that apply: Neck Upper Back Shoulders/Arms Mid-Back Lower Back Glutes Thighs/Lower Legs Are you currently taking any medications or supplements? If yes, please list: Do you have any allergies? If yes, please list: Do you have any skin conditions? If yes, please list: Please agree to the following by selecting all boxes: * I am 18 years of age, or have the permission of my parent/legal gaurdian. I understand that it is my responsibility to ask questions or bring up concerns to my therapist at the start of my appointment. If I experience any discomfort during the service, it is my responsibility to tell my therapist. I understand that massage therapy is not a substitue for medical intervention with a serious condition or illness. I understand that any sexually suggestive, illicit, or other remarks that make my therapist uncomfortable during the appointment, will result with immediate termination of the appointment and I will still be responsible for full payment. Signature: * By typing in my name below, I confirm that I have answered all the information accurately. I also agree to accept all and full responsibility for any risks, injuries, damages, or side effects that may occur as part of the massage appointment. I will not hold Integrative Massage By Liz responsible for any conditions present but not disclosed. I understand that full payment is required after each session and cannot be paid at a later time. If for any reason I cannot make an appointment, I understand that I am required to cancel my appointment prior to 24 hour before my appointment. Failure to do so, or missing an appointment entirely, will be subject to a fee. First Name Last Name Date * MM DD YYYY Thank you!
