Warning: Invalid argument supplied for foreach() in /home/rams001/public_html/wp-includes/class-wp-post-type.php on line 526 Massage Intake Form : Rain Massage Therapy

Massage Intake Form

Client Name:
Referred by:
ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE
CELL PHONE
MALE/FEMALE
BIRTH DATE
AGE
MARITIAL STATUS:S/M/D/W
EMAIL
DRIVER’S LIC. #:
WORK/BUSINESS:
WORK PHONE
Can you be called at work about appointments?
Whom do we contact in an Emergency?
PHONE
Relationship:

Are you under a Doctor’s care?

Dr.
Doctor’s address
Phone

Are there any Chronic Problems? WHAT?

Do you have any heart problems? WHAT?

Do you have Diabetes? What Type? How Long?

Do you have Kidney or Bladder problems? What?

Do you have Chronic Pain? Where? Constant/Intermittent/How long have you Had this?

Allergies/Sensitivities?

Present Medications:

Please describe your chief Complaint(s), at this time:

Please relay any information that may interfere with receiving massage: (active, Cancer, broken bone, pregnancy, etc..)

I will be paying for my Massage(s) by
CashCheckCredit CardGift Certificate

Your appointment time(s) are reserved for you. 24/72 hours notice is required to cancel an appointment. If unable to fill the cancelled/missed or frequently reschedule appointment, you may be required to pay for appointments. _____initials No Refunds on Gift Certificates or Pre-paid packages.

MM12748/MA23791