New Client Form for bodywork & massage

Name *
Name
Date of Birth *
Date of Birth
Phone *
Phone
Address *
Address
How did you hear about MELT?
Who should we call in case of an emergency?
Emergency Contact Phone *
Emergency Contact Phone
Have you had a massage before? *
Please check all conditions that apply now, past conditions, family history conditions.
May I contact you via mail/email about future promotions and news?
*
All information obtained on this form will be kept strictly confidential. Certain medical conditions may be contraindicated for massage or may need a physician’s referral prior to receiving massage. I understand that the massage I receive is provided for the purpose of basic relaxation and relief of muscle tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure/strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for a medical examination, diagnosis or treatment and that I should see a qualified medical specialist for any ailment. I acknowledge that massage should not be performed under certain medical conditions and I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and I understand that there shall be no liability on the practitioner’s part should I forget to do so. I state that I have consumed no intoxicating substance or non-prescribed drug prior to arriving for bodywork.