Home
About
Services
Shop
Specials
Blog
Forms
Contact
Book Online
Back
About Laura
What To Expect
Back
Skin Care
Acne Program
LED Light Therapy
Waxing
Massage
Back
Products
Gift Cards
Home
About
About Laura
What To Expect
Services
Skin Care
Acne Program
LED Light Therapy
Waxing
Massage
Shop
Products
Gift Cards
Specials
Blog
Forms
Contact
Love your skin
Book Online
New Client Form for bodywork & massage
Name
*
Name
First Name
Last Name
Date of Birth
*
Date of Birth
MM
DD
YYYY
Email Address
*
Phone
*
Phone
(###)
###
####
Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Referred By:
*
How did you hear about MELT?
Emergency Contact Name
*
Who should we call in case of an emergency?
Emergency Contact Phone
*
Emergency Contact Phone
(###)
###
####
Primary reason for appointment/ areas of pain or tension
*
Have you had a massage before?
*
Yes
No
Please check all conditions that apply now, past conditions, family history conditions.
headaches, migraines
hearing problems, deafness
vision problems, contact lenses
injuries to face or head
dental bridges, braces
hernia
muscle/joint pain
muscle, bone injuries
numbness or tingling
sprains, strains
arthritis, tendonitis
cancer, tumors
spinal column disorders
jaw pain, TMJ problems
asthma or lung conditions
constipation, diarrhea
chronic pain
heart, circulatory problems
pregnancy
diabetes
digestive problems
high/low blood pressure
fatigue/depression
tension/stress
allergies/sensitivities
sleep difficulties
infectious disease
rash, athletes foot
blood clots
varicose veins
transdermal patches
lymphedema
other conditions not listed
Explain any areas noted above
Current medications, including over the counter medications and vitamins/herbs
Surgeries/Accidents
May I contact you via mail/email about future promotions and news?
Yes
No
*
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.
I Agree
Thank you!