New Patient Intake

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New Patient Intake

Please complete intake form as honestly and accurately as possible...

Email *

Full Name *

Date of Birth *

YYYY

Have you had a professional massage before? *

Yes

Are you currently in treatment or under the care of a Physician? *

Yes

N/A

If "yes", please explain here...

Please list any and all medical conditions, disorders, or diseases: *

or None N/A

List any and all skin or dietary allergies here... *

or None N/A

Please list any major injuries, hospitalizations, or surgeries here...

How is your Body Feeling?

Left

Right

Needs Extra Attention

Soreness/ Tension

Acute Pain

Chronic Pain

Surgery/Implant/ Medical Device

Avoid/ Do Not Work

1: Head/Face/Jaw

2: Neck/Cervical Spine

3: Shoulder(s)

4: Arm(s)

5: Hand(s)/Finger(s)

6: Chest/Ribs

7: Stomache/GI Tract

8: Hips/Pelvis

9: Back/Thoracic Spine

10: Low Back/Lumbar Spine

11: Leg(s)

12: Feet/Toes

13: Knee(s)

Please elaborate on how your body is feeling here...

Review and Check all upon understanding: *

I have completed this new patient intake honestly and to the best of my ability.

I understand that my licensed Massage Therapist is providing a professional health treatment at their discrepancy, and may refuse or end service at any time for any reason.

I understand that Healing Massage LA and its therapists are fully insured with the AMTA and in any case of irreconcilable patient grievance, I agree to arbitration per the requirements of the liability insurance policy enacted.

I agree to communicate with my therapist at any time if I experience any discomfort or have any questions.

I agree to communicate with my therapist if there are any changes in health or to this intake form.

I agree to complete a COVID-19 attestation before each appointment until further notice.

Required

Sign and Date: *

Type your full name to acknowledge your completion of the above intake...

Today's Date *

YYYY

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