Intake Form

Client Intake Form – Erin’s Therapeutic Tounch, LLC.

Name                                                                                                    Phone                                                                 

Address                            ____________                                     City/State/Zip                                                           

DOB                                                          Emergency Contact Name & Phone #                                                      

Have you had a professional massage before                                                                  Yes            or            No

Do you have any difficulty lying on your front or back                                                  Yes            or            No

Do you have any allergies to oils, lotions, or ointments                                                 Yes            or           No

Are you currently under medical supervision                                                                   Yes             or           No

If yes, please explain                                                                                                                                                        

Do you see a chiropractor                                                                                                     Yes              or           No

Are you currently taking any medications                                                                        Yes              or           No

If yes, please list                                                                                                                                                             

Please circle any areas you would like me to concentrate on during the session.

Erin Varney

Is there any area you don’t want massage?                                                                                                                       

Draping will be used during the session-only the area being worked on will be uncovered. Clients under 18 years of age must be accompanied by a parent of legal guardian during the entire session.

I understand that the massage I receive is provided for the basic purpose of relaxation & pain relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure &/or stoke may be adjusted to my level of comfort. I have also read & understand the payment policy.

 

This massage is NOWAY sexual! If you insinuate it in anyway the session will end & you will pay in full.

Signature of client                                                                                           Date

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