New Patient Intake

Name

Phone

Address

Email

Sex

Date of Birth

How did you hear about us?

Have you experienced a professional massage or body work session before?

If yes, how recently?

What are your massage or body work goals?

Do you frequently suffer from stress?

Are you pregnant?

If yes, for how long?

Do you suffer from arthritis?

Are you wearing contact lenses?

Do you have high blood pressure?

Do you take high blood pressure medicine?

Do you suffer from epilepsy or seizures?

Do you suffer from joint swelling?

Do you have varicose veins?

Do you have any contagious diseases?

Do you have allergies?

If yes, please list all allergies below.

Do you bruise easily?

Have you had any broken bones or injuries in the past 2 years?

if yes, please explain.

Do you have cardiac or circulatory problems?

Do you suffer from back pain?

Do you have numbness or stabbing pains?

Are you sensitive to touch or pressure in any area?

If yes, please explain.

Do you have osteoporosis?

Are you currently undergoing treatment for cancer?

Do you have any other medical conditions and/or medication?

If yes, please explain below.

Have you had any surgeries?

If yes, please explain below.

Have you been asked to self-isolate or quarantine by a doctor or health official in the last 14 days?

Have you experienced any cold or flu like symptoms in the past 14 days?

Have you had close contact or cared for someone diagnosed with COVID-19?

Have you ever been tested for COVID-19 and what was the result?

I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive treatment from this practitioner.

I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event that are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.

Client Waiver Form - Please take a moment to read and check the following information .

I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand that the services offered are not a substitute for medical care.

I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.

I affirm that I have notified my therapist of all known medical conditions and injuries.

I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.

I understand that massage is entirely therapeutic and non-sexual in nature.

By checking this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

I understand the cancellation policy (we require a 24 hours notice cancellation, if cancelled within less than 24 hours, you will be charged 50% of the paid services - no call no shows will be charged 100% of the paid services)

New Patient Intake Form

Come relax with us.

Contact Us

570-982-6994

relax@tranquilmomentsofthepoconos.com

409 Route 940

Suite 100

Blakeslee, PA 18610

License #MSG012791