New Client Intake Form
🌴💆🏻‍♀️💆‍♂️Kindly READ the Following Information Carefully + Provide the information Requested below, so that we may better serve you.

CONSENT FOR CARE:
It is my choice to receive massage therapy by Blissful touch Body + Reflexology. I am aware of the benefits and risks of massage and give consent for massage. I understand there is no implied or stated guarantee of success or effectiveness of individual techniques or series of appointments. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, or other qualified medical specialist for any ailment that I am aware of.

I understand the massage/bodywork practitioners are not qualified to perform chiropractic adjustments, diagnose, prescribe, or treat any physical and mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I will state all my known medical conditions and answer all questions honestly on the form below. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability of the practitioner’s part should I fail to do so.
Name ( First and Last ) *
Are you over the age of 18? *
חובה
Date of Birth ( Month and Day ) *
Do you agree to the terms listed in the box above? *
חובה
How did you hear about Blissful touch Body + Reflexology? *
חובה
Kindly List all Current Prescribed Medications. *
Kindly List any OTC ( Over the Counter ) medications / supplements *
List any Allergies. *
Kindly list all Surgeries / Injuries. *
What is the Reason for your Visit? Are there any areas of the most concern for you? *
Would you like your therapist to AVOID any of these areas? *
חובה
Emergency Contact. Kindly Provide Full name, The Relationship and their BEST Contact Number. *
By signing this waiver, I agree to the above terms and conditions. *
חובה
I certify that the information I have provided above is accurate to the best of my knowledge. *
חובה
I understand the scope of massage and that it is not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care. *
חובה
שליחה
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