New Client Intake Form

After scheduling your appointment, please click the link below to complete your “Intake Form.” If the form is not completed in advance, ensure you arrive early to fill it out. Please be aware that appointment times are fixed and cannot be extended. Thank you for your understanding. If you have not booked your appointment yes, please

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Client Information

Treatment Booked

Thai Massage

Mobility

Pregnancy (3rd Trimester)

First name

Last name

Address

Phone

Birthday

Month

Day

Year

Emergency Contact Name & Number

Reason for Visit

Describe reason for todays visit

Describe your treatment goals

Have you had a massage?

Yes

If yes, how long ago?

Have you received other treatment? If yes, check all that apply

Chiropractic

Physical Therapy

Acupuncture

Other

Are you currently under an orthopedic or sports medicine teams care? If yes, who?

NOTE: Thai Massage applies deep yoga style stretches, please have permission from your physician if you are being treated by the orthopedic or sports medicine team.

Health History

Your therapist utilizes techniques that may not align with certain diagnoses. Kindly share all that apply to you, allowing your therapist to create the safest and most effective treatment plan.

Please rebook of you are experiencing a flareup

Women's Health

Natural Birth

C-Section

Currently Pregnant

If you are currently pregnant, please rebook if you are not in your third trimester.

Your therapist may use oils, lotions or creams that may contain nuts, fruits, or skin irritants. Any known Allergies? If yes, please list

Your therapist uses modalities that my conflict with certain medications, are you on any medication? If yes, please list

This booking is for a minor: Please check both boxes before moving forward.

I understand a parent/guardian has to be present for the full duration of the treatment provided by Create Health Mobility Clinic.

I understand failure to do so will result in the treatment canceled and rescheduled for a date said parent/guardian is available.

Waiver: Please Read and Sign

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 today's services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/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 and 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. Comments or gestures will not be tolerated resulting in termination of current and all future sessions.
I understand that, because massage therapy work involves maintained touch and close proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. I agree to cancel and/or reschedule session should such diagnosis occurs.
I have read your cancelation policy and agree to the terms and conditions
By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.

I have read the above statement and agree to all policies. I further authorize my digital signature.

If you decline authorization via digital signature, please type "DECLINE" and submit the form. A authorization for a written signature will be provided at the time of your appointment.

Date

Month

Day

Year