New Client Appointment Request
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Agreement:
By
submitting this form I acknowledge wtih my signature the following: 1)
I have read the description of the massage I am requesting and
understand the techniques of that specific massage modaity. 2) If I do
not want any portion of my body massaged, I have indicated those areas
in the "special requests" box below or will convey them at the time of
the session. 3) If I am uncomfortable for any reason, I may ask for the
massage to cease and the masseur will end the session immediately. 4)
Draping will be used unless I request no draping at the time of the
session. 5) I have listed all of my medical conditions on this
form and will update the masseur prior to a massage should any new
conditions arise.
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| First Name:: |
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| Last Name:: |
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| Phone:: |
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| Email:: |
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| Age:: |
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| Gender:: |
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| Height/Weight:: |
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| I would like to schedule the following session type:: |
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| I would like to schedule my session for the following Date & Time:: |
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| Please indicate which (if any) of the following conditions apply to you: allergies, arthritis, joint disorders, frequent headaches, vericose veins, blod clot, spinal problems, recent injury or surgery, pregnancy:: |
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| Please list any other medical conditions/issues I should be aware of:: |
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| Areas of complain, pain, tension:: |
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| Special Requests:: |
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| Signature: |
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