*Need a new client form?  Here is one that has everything you need.  Just paste it into word and format!

New CLIENT REGISTRATION

Date: _____________________

Name: _______________________________________________

(Last)                                  (First)                              (Middle Initial)

Gender:    o M      o  F

Date Of Birth: ______________

Address:_______________________________________________________________________________________

City: ____________________ State: _____ Zip: __________ Phone _______________ Email___________________

Where do you work (what kind of work do you do?)______________________________________________________

Emergency Contact ______________________ Phone __________________

Please let us know how you found us? ______________________________________

Medical History and Information

Check any or all that apply to your present health:

___ headaches                                      ___chronic pain                        ___varicose veins

___ vision problems                               ___muscle or joint pain              ___blood clots

___ sinus problems                                ___numbness/tingling                ___high/low blood pressure

___ jaw pain/teeth grinding                    ___sprains/strains                     ___diabetes

___ fatigue                                           ___scoliosis                              ___cancer/tumors

___ depression                                      ___arthritis                               ___infectious disease

___ sleep difficulties                              ___tendonitis                            ___skin problems or allergies

Women only:  ___Pregnant___  Painful menstruation___  endometriosis

Other not listed_____________________________________________________________________________

List all medications/herbs/vitamins and dosage: ___________________________________________________

What movements or activities are limited? (what aggravates it?)_________________________________________________

List previous major injuries/surgeries:___________________________________________________________

_______________________________________________________________________________________

What other treatments are you receiving and by whom (acupuncture, physical therapy, chiropractic, naturopathic): ______________________________________________________________________________

Is there anyone you want us to copy on your treatment progress?  Y  /  N   If Yes, what is your doctors /practitioners name?______________________   Phone number _________________

POLICY – PLEASE READ

• If cancellation is necessary, please give 24-hour notice.  If you do not give notice you will be charged a $25 fee at your next appointment.  The 2^nd time it happens and anytime thereafter, you are charged for the full price of the massage missed.  Emergency cancellations are determined at the practitioner’s discretion.
• Sessions begin and end at scheduled times. If you arrive late, you will lose that time off your session and will still be charged full price.
• If you have a cold, flu, sore throat, stomach virus, poison ivy, skin rash, anything contagious please reschedule your appointment.
• Please do not be under the influence of alcohol or drugs because massage can be dangerous to you under these conditions.
• Clients must provide a health history and update when necessary.
• Payment is expected at the time service is rendered.
• Sexual harassment is not tolerated.
• If the practitioner’s safety feels compromised, the session is stopped immediately.
• Please shower prior to your session as clean skin is easier to work on.
• Do not eat a heavy meal less than two hours prior to the treatment.
• Wear loose or comfortable clothes

Your name here are not responsible for the loss of your valuables or personal property.   If you want me to lock away your items, just ask prior to the session.  Please check the room for your valuables, such as jewelry and glasses

Client Signature                                                                                                  Date

Massage Therapy Informed Consent

I, _____________________, (client) understand that massage therapy provided by, your name here is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch.  The general benefits of massage, possible massage contraindications and the treatment procedure have been explained to me. I understand that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not part of massage therapy. I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes. I understand that there shall be no liability on the practitioner’s part due to my forgetting to relay any pertinent information. If I experience any pain or discomfort during the session, I immediately communicate that to the therapist so the treatment can be adjusted. I have reviewed the therapist’s policies, and I understand them and agree to abide by them.  I acknowledge that with any treatment there can be risks and I assume those risks.

Client Signature                                                                                                  Date