Massage Intake Form - Unlimited Mindset, LLC

Name *

First

Last

Date Of Birth *//

Gender *

Male
Female

Are you pregnant? *

Yes (If so please reschedule, prenatal massages are not done at this location.)
No
Not applicable

Email *

Phone Number *

Massage Service Location *

Office Location

Is this a Groupon Gift Cerificate? *

No
Yes

Massage Service Duration *

Groupon Massage Service Duration *

Date and time of scheduled appointment. *

Date

Time

The best way to contact you. Check all that apply. *

Phone Call
Mobile Text
Email

May I contact you about Massage & Wellness Program? *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Occupation

Emergency Contact Name *

Emergency Contact Number *

Have you had a professional massage before? *

Medical History & Allergies (List anything that your therapist needs to be made aware of.) If there is nothing type NA. *

In order to plan a massage session that is safe and effective, I need some general information about your medical history. PLEASE EXPLAIN IN DETAIL!

COVID-19 Related Questions

Have you had a fever in the last 24 hours of 100°F or above? *

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? *

Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions? *

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *

Have you traveled anywhere outside of the state in the last two weeks? *

If you have traveled outside the states where? If not put NA in the box. *

PLEASE READ AND CHECK IF YOU AGREE TO THESE TERM & CONDITIONS. *

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage 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 that I am aware of. I understand that massage therapists 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 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Sign & Date Below *

Today's Date *

COVID-19 Related Questions

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