CLIENT INTAKE FORM

Client Intake Form
First Name
Last Name*
Date of Birth*
Occupation
Mailing Street
Mailing City
State
Mailing Zip
Mailing Country
Phone*
Email
Appointment Reminder Preference
Date of First Visit
Emergency Contact
Emergency Contact Phone
Who referred you to Hunter Massage Clinic?
Primary Condition*
Secondary Condition
Other Conditions/information
What events have contributed to your condition?
How long have you had this condition?
Exactly how long have you had this condition?
Diagnostic Tests
Who have you sought help from for this condition? Select all that apply.
If you selected Doctor, what type of doctor?
What type of treatment have you sought? Select all that apply.
How does your body feel during the day?
What would significant relief look like to you?
Please understand that your time commitment begins at the moment you reserve a massage. In order to make it fair to everyone, please consider your schedule carefully and don’t commit to a time that you feel may be questionable. There are times when a cancellation is necessary, but please give advanced notice whenever possible. We usually have a waiting list so if you call the morning of your appointment, at the latest there will be no charge to you. However, missed appointments without a call will be charged in full. (real unforeseen emergencies excluded).*

Please check this box to agree.
I understand that the massage I receive is providing for the basic purpose of relief of muscular tension/tightness and relaxation. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or physical or mental treatment and I should see a physician, chiropractor or other qualified medical specialist for these conditions. I also understand that nothing said in the course of the session given should be construed as such. I affirm that I’ve answered in the intake form honestly and agree to update the therapist on any new medical condition that I have. I volunteer to receive these massage sessions because of my own personally held belief that massage may be beneficial for my symptoms of muscular tightness and tension. I hereby hold harmless and indemnify the therapist, their principals and agents from all claims and liability whatsoever.*

Please check this box to agree.
I hereby grant permission to the rights of my image, likeness andsound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material my be used in diverse education settings and marketing within an unrestricted geographic area. By signing this release I understand this permission signifieds that photographic or video recording of me may be electronically displayed via the internet and may be used for conference, educational, marketing, informal presentations. There is no time limit on the validity of this release and no geographic limitations.

By checking this box I acknowledge that I have completely read and fully understand and agree. I hereby release any and all claims against any person or organization utilizing this material.*

Please check this box to agree.