65 - Forms Junction

CLIENT DETAILS

Date *

Client Name *

First

Last

Date of Birth *

Sex *

Email *

Cell Phone Number

Home Phone Number

Work Phone

Can We Leave a Message?

Home
Cell
Work

Please tick all that apply

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Current or Previous Occupation *

EMERGENCY CONTACT INFORMATION

Emergency Contact's Name *

First

Last

Contact Number *

Relation to Patient *

Current Healthcare Provider Contact Information

Please add a contact phone number and email address

MEDICAL DETAILS

Have Have You Had a Theraputic Massage Before?

Are You Currently Under Care of a Physcian/Chiropractor?

If yes, please detail the reason

Please Detail Any Current or Previous Injuries or Surgeries

Please Detail Any Allergies

Please Detail All Medication You're Currently Taking

Current Exercise/Training Routine

Please detail your current exercise schedule

Please Detail Any Current Pain, Tension, or Discomfort Areas

Arm, leg, neck, etc.

FINAL STEPS

Terms & Conditions *

I hereby agree to the following terms and conditions:

Welcome to _________. Because the Terms and Conditions contain legal obligations, please read them carefully.

1. YOUR MASSAGE AGREEMENT

By agreeing to this, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use click agree.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

2. PRIVACY

Your information will be logged in our system and will not be shared with 3rd parties.

Client Signature *

How Did You Hear About Us?

Additional Questions or Comments

65

CLIENT DETAILS

EMERGENCY CONTACT INFORMATION

MEDICAL DETAILS

FINAL STEPS

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