Studio Slōō, LLC

Client First and Last Name:

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Address:

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Phone:

125393558026

Email:

romnik2012@code-gmail.com

Referred by:

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Are there any injuries or surgeries your practitioner needs to be aware of?

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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?

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Will you be wearing contacts during your session?

No

Will you be wearing dentures during your session?

No

Are you pregnant?

No

If yes, how far along are you?

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Is your pregnancy high risk?

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Please list any allergies or hypersensitives:

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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?

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Please click each categories below to check any conditions you may have.

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Any other condition your practitioner should be aware of?

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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)

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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)

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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)

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I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. (Sign name below)

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Write your full name below for signature

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Emergency Contact Name:

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Emergency Contact Phone:

125393558026

Comments:

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(Optional) Please list your favorite genre of music you enjoy for relaxation

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Completed on Oct 19th, 2024