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Studio Slōō, LLC
Completed on Sat, Oct 19th 2024
New Client Intake Form
Client First and Last Name:mz13nm
Email:romnik2012@code-gmail.com
Are there any injuries or surgeries your practitioner needs to be aware of?d12eoc
Do these symptoms interfere with your daily living activities? ( e.g., sleep, exercise, work, childcare)?No
Are there any medications and conditions they're treating your practitioner needs to be aware of?lbtkyw
Will you be wearing contacts during your session?No
Will you be wearing dentures during your session?No
If yes, how far along are you?8ft33i
Is your pregnancy high risk?cdcg5p
Please list any allergies or hypersensitives:kvub0h
Have you ever received professional massage/bodywork before?No
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?No
What are your goals/expected outcomes for receiving massage/bodywork?c1p2z7
Please click each categories below to check any conditions you may have.6xi36s
Any other condition your practitioner should be aware of?o1j5ss
The above information is accurate to the best of my knowledge. It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. (Sign)c37phr
I understand that no inappropriate comments or conduct will be tolerated. Any indication of such will terminate the session and result in a full charge of the service. (Sign name below)m4awi3
I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. (Sign name below)6ovqk7
I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. (Sign name below) uc80uz
Write your full name below for signatureby3c5a
Emergency Contact Name:si9yqr
Emergency Contact Phone:125393558026
(Optional) Please list your favorite genre of music you enjoy for relaxation tjhpdd