NEW CLIENT FORM

Name
Name
Address
Address
Phone
Phone
Birth Date
Birth Date
PLEASE ANSWER THE FOLLOWING QUESTIONS:
Have you had a professional massage before?
Have you had a reflexology session before?
Do you have any heart problems?
Any spinal problems?
Do you have any skin problems or allergies?
Are you pregnant?
Do you have high blood pressure?
Do you take any prescribed medications?
Do you have varicose veins or blood clots?
Do you have arthritis?
Notice
A massage therapist/reflexologist does not diagnose illness, disease or any other physical or mental disorder. Massage therapists/reflexologists do not perform any spinal manipulations. It have been made very clear to me that this massage therapy/reflexology treatment is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have. Because a massage therapist/reflexologist must be aware of existing physical conditions, I have stated all know medical conditions and take it upon myself to keep the massage therapist/reflexologist updated on my physical health.
I UNDERSTAND THAT A STUDENT WILL GIVE MY MASSAGE. IF I DESIRE A TIP, IT GOES TO THE STUDENT.
I understand that typing my signature here represents my signature and that I confirm the above information to be true to the best of my knowledge.
DATE
DATE