Feel Better Healing Place

Feel Better

Client Intake Form

The Feel Better Healing Place

Laura Nicole, LMT #18446

Client Name: ________________________________      Date: ___________________________

Email:____________________________________________________   

Phone number: _____________________________        Birthday: _______________________

Referred By: _________________________________    

Emergency Contact & Phone #: _______________________________________________________

Have you had a massage before?:             ______ No          ______ Yes         Last one: ______________

What type of pressure do you prefer?   ______ Light        ______ Medium              ______ Firm

Any specific areas that need extra attention:______________________________________________

 __________________________________________________________________________________

Any specific areas to avoid: ____________________________________________________________

Allergies: ___________________________________________________________________________

Are you Pregnant:           ______ No          ______ Yes         Due Date: ______________

Do you have any questions before we begin?: _______________________________________________

Consent for Treatment If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or 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 have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

 Client Signature: _________________________________           Date: __________________________

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