Date MM DD YYYY Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Occupation Emergency Person & Phone * What are you goals for this treatment session? * How did you hear about us? Interests? * Consult Yoga Breath Work Private Session / Personal Training Massage Thai Stretching Reiki CranioSacral Therapy Lymphatic Massage for Detoxification Cupping Limpias / Energy Clearing Into the Forest Abdominal Massage Home Blessing Ear Candling Skin Care Treatment Oracle Readings w/ Lauren Singing Bowls w/ Lisa SPINE Academia Yoga Teacher Training Medications Please Provide Names and what for. Do you suffer from chronic pain? If so, please explain & share what makes it worse or better. Any Surgeries? If so, please provide dates & type of surgery. Please indicate any of the following that apply to you: Cancer High / Low Blood Pressure Asthma Anxiety Depression Arthritis Fibromyalgia Stroke or Heart Attack Joint Replacement Kidney Disfunction Blood Clots Neuropathy or Numbness Sprains or Strains Thyroid Imbalance Lymes Disease Anemia Autoimmune Challenges Constipation or Digestive Challengers Have you had a Professional Massage Before? If, so please share pressure preference. Yes No Light Pressure Medium Pressure Heavy Pressure Allergies or Sensitivities If so, please provide details. ~ 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 the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or 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. I understand 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. ~ By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork. ~ I have received the policy statement, and have read and agree to the policies therein. * Any Questions or Comments? Signature * First Name Last Name Thank you!