New Client Intake FormThank you for taking the time to fill this out before your appointment. Name * First Name Last Name Email * Phone * (###) ### #### Pronouns * Please select your pronouns She/Her He/Him They/Them Please review this list and check those conditions that have affected your health recently or in the past. Arthritis Anxiety Diabetes Blood Clots Depression Whip lash Cancer Broken/Fractured Bones Chronic Pain Constipation/Diarrhea Hepatitis (A, B, C, other) Allergy or sensitivity to lotion TMJ disorder Skin Conditions Stroke Surgery Insomnia Headaches/Migraines Auto-Immune Condition Heart Condition Strain/Sprain/Injury Dislocation Injury High Blood Pressure Pregnancy Scoliosis Seizures Chemical Dependency (alcohol or drugs) Currently have a contagious rash Wearing a hair piece (wig, extensions) Lymph nodes removed/Disrupted Other If any of the above need to be detailed or if there is anything else you would like to share, please do so here: Are there any areas you dislike being worked on? IE: feet, scalp, glutes, face What are your goals for today’s session? Problem Areas? How did you find The Conscious Bodyworker? Did somebody refer you? * Terms and Conditions 1. I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the therapist so that the pressure may be adjusted to my level of comfort. I further understand that massage should not be constructed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be constructed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all the questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. 2. This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment. 3. I am showing no signs of covid-19 and do not believe I have been exposed to it in the last 14 days 4. No shows or cancellations less than 24 hours will be charged full fee. Cancellations under 48 hours will be charged 50%. I agree to these terms and conditions. Date MM DD YYYY Digital Signature (guardian signature for clients under 17) * Thank you!