New Client Health Intake Form - Wild Sage Bodywork/Jennifer Gibson MT

Please answer the health intake form as thoroughly as possible.

1. Date:*

2. Client Name:*

3. Date of Birth:*

4. Phone:*

5. Address:*

6. Email:*

7. Physician/Health-care Provider Name:*

8. Physician/Health-care Provider Phone:*

9. Emergency Contact Name:*

10. Emergency Contact Phone:*

11. How did your hear about Jen & Wild Sage Bodywork?*

12. Have you ever received professional massage/bodywork before?*

Yes

No

13. How many of the following bodywork modalities have you received in the past?*

14. What are your goals & expected outcomes for receiving massage/bodywork?*

15. List the medications you currently take & what condition they are for:*

16. Please select any of the health related conditions that you have now or have had in the past: *

17. Do you wear any of the following?*

Contacts

Dentures

Hearing Aids

None of the above

18. Have you had any injuries, car accidents, falls or surgeries in the past. If yes, please list the year that they occurred.*

19. List and prioritize your biggest areas of concern. Please include your current symptoms/issues in these areas:*

19. Do these symptoms interfere with your activities of daily living (ie sleep, exercise, work, childcare)?*

Yes

No

20. Please check all areas of the body in which you are willing to have bodywork:*

21. Are you interested in receiving Breast/Full Chest Massage? (Please note that an additional consent form will need to be filled out to receive this service)*

Yes

No

Need more info before I decide

Consent to Treat- Please check ALL boxes below to show you understand the following:

I agree to tell Jen if I have pain during my session so that she can change technique accordingly

I understand that bodywork does not substitute a medical exam, diagnosis or treatment

I understand that Jen, as an MT, is not qualified to diagnose or prescribe for any illness

I affirm that I have a provided all known medical conditions & answered all questions honestly

I agree to immediately update Jen of any changes to my medical profile

If I fail to update Jen of these profile changes, there shall be no liability on Jen's part

I agree that any sexually suggestive behavior will result in ending the session immediately

Understanding all of the above, I give my consent to receive care

Office Policies- Please check ALL boxes below to show you understand the following:*

Payment is due before or at the time of service.

Accepted forms of payment: cash, check, credit card, Paypal, Venmo. $35 fee for bounced checks

24 hours notice is required for cancelations, except in cases of emergency

50% of the scheduled session fee is due for late cancelations (within 24 hours) or no shows

If you have any COVID related symptoms, please cancel your session with Jen with NO cancelation fee

Jen does not take insurance claims, but can supply you with a detailed receipt for reimbursement

Write your full name below for signature*

Enter today's date*

Write your full name below for signature (in case of a minor) as guardian or parent

Enter today's date (in case of a minor)

I give consent as parent or guardian for my child, under the age of 18, to receive bodywork from Jennifer Gibson MT of Wild Sage Bodywork. Signature Below.*

I understand that all minors under the age of 16 must be accompanied by a parent or guardian during their session.*

Check the box if true