serenitypdx - serenitypdx

Name(*)

Please enter your name.

Today's Date(*)

/ / Please enter today's date. (mm/dd/yyyy)

E-mail(*)

Please enter a valid e-mail address.

Phone Number(*)

Please enter your phone number.

Birth Date

/ / Please enter your birth date. (mm/dd/yyyy)

Address

Invalid Input

City

Invalid Input

State

Invalid Input

Zip Code

Please enter a numeric value.

Referred By (optional)

Invalid Input

What is your primary goal for massage therapy?

Invalid Input

What type of work do you do?

Invalid Input

Please explain any recent (within the past 3 months) issues with soreness, pain, stiffness, or decreased mobility:

Invalid Input

Please explain any chronic issues (issues lasting more than 3 months):

Invalid Input

Do you have any areas that should not be massaged? (Ex. Injured, open wounds, bruises, ticklish)

Invalid Input

Please list any recent or lingering injuries, surgeries, or major illnesses:

Invalid Input

Are you currently under the care of a physician? Please list name of physician and reason:

Invalid Input

Please list any medications, supplements, or herbs you are currently taking and any side effects:

Invalid Input

Are you allergic or sensitive to any scents, oils, or lotions?

Invalid Input

PregnancyInvalid Input

How far along?

Invalid Input

OtherInvalid Input

Please describe:

Invalid Input

Intake Agreement(*)

The above information is true to the best of my knowledge. I take full responsibility for making my therapist aware of any changes to my health. I understand that massage therapy is not a substitute for professional medical attention. I understand that massage therapists do not diagnose disease, prescribe medication, or manipulate bones. I understand that sexual misconduct of any kind will not be tolerated. For the comfort of both client and therapist, the client will be draped throughout the entire massage session. No exceptions. I reserve the right to end the massage at any time and so does my massage therapist.You must agree to this statement in order to receive a massage.

(*)

Invalid Input

Intake Form