Sarah Rose Therapies Client Intake Form

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number

Format: (000) 000-0000.

E-mail

Emergency Contact

Phone Number

Format: (000) 000-0000.

Occupation

Doctors Name and phone number

Medications

Allergies

Health Information

Are you currently pregnant or breastfeeding?

Please indicate if any of the following apply to you.

What would you like to achieve from your appointment? E.g. Relaxation or Specific areas of concern

What Pressure to you prefer?

Frequency of pain or concern - please select the most accurate

Neck

Shoulders

Arms & Hands

Mid-Back

Low Back

Hip

Legs and Feet

Client Agreement:

I understand that therapeutic massaage, reflexology,enegy therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that holistic therapies are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic treatments as a form of therapy.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic therapist so they adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Pure Touch Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.

Please Tick if you would like to receive information on special offers from Sarah Rose Therapies.

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Date

MonthDayYear