Massage Therapy Intake
Thank you for taking the time to fill out this massage therapy intake form. I look forward to our session!
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Email *
Name *
Personal Pronouns
Full Address *
Phone number
May I text this phone number?
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Emergency Contact ( Name &  Phone Number)
Who can I thank for referring you?
Date of Birth
MM
/
DD
/
YYYY
Have you had professional massage before?
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What is your primary reason for scheduling this massage?
Hydration: how many ounces of water to you drink per day?
Current physical activity level? Sports/hobbies past or present?
Please list any medications/supplements/vitamins you take.
Please list any allergies/sensitivities you have (food, medicine, environment, scents, etc.)
Are you working with a provider (including for pregnancy)? If so, who?
Please check any of the following boxes that apply to you, past or present. *
Please elaborate on any checked conditions above.
If you have a uterus, please check any boxes that apply to you, past or present.
Please elaborate on any checked boxes above.
If pregnant, please check any boxes that apply.
Covid-19 Status *
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Have you travelled outside of CT in the past 2 weeks? If so, where? *
Are you exhibiting any of the following symptoms? (If so, please promptly reschedule/cancel your appointment) *
Is a member of your household Covid positive? (If so, please promptly reschedule/cancel your appointment) *
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Are you fully vaccinated against Covid-19? (Vaccination is NOT required to visit )
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Any comments or additional information you would like known?
Appointment Requests/ Responsibilities & Notices
Please make all efforts possible to cancel or reschedule appointments with at least 24 hours' notice. Please arrive on time for appointments. Late arrivals may result in a shortened massage session but full payment will be required. Kaitlin’s role as a birth doula requires her to be on call for Doula clients and therefore, on very rare occasions, there may be a need to cancel massage appointments with short notice or possibly even need to interrupt the session. Should this happen, she will make every effort possible to reschedule your session as soon as possible.
Release of Liability
By signing this agreement, I understand that the care by my massage therapist, Kaitlin Gee, is in no way to be construed as medical treatment, nor are any suggestions or recommendations provided by her to be construed as medical advice. I understand that Massage may be contraindicated or modified for certain health problems I therefore release Kaitlin Gee from any liability should I have failed to provide all medical and health information. I take responsibility that I shall update Kaitlin about health conditions at future appointments. I understand that massage therapy is to be used as a complement to medical care and never as a replacement. I understand that if I experience any discomfort during my session for any reason, I will notify my therapist immediately.
By typing your first & last name below you agree that all of the information provided is correct to the best of your knowledge and that you have read the Appointment Requests/ Responsibilities & Notices and the Release of Liability above. Please type your name and the date below:
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