client intake form

First Name

Last Name

Today's Date

Date of Birth

Day

Month

Year

Address

Phone

Emergency Contact: Name and Phone

Health Fund

Occupation

Exercies (type and frequency)

Hobbies / most frequent activities

Please list and explain any previous injuries, trauma or major illnesses. Include dates.

Please list and explain any previous surgical procedures. Include dates.

Are you currently under medical supervision?

Yes

if you are under medical supervision, list conditions:

Who is your Doctor?

Are you currently taking any medication (prescribed, over the counter, herbal, etc)?

Yes

If yes, please explain

Do you have any allergies to essential oils?

Yes

Are you, or do you think you may be pregnant?

Yes

N/A

What is the intention/goal of your visit?

Please write down any additional information regarding your health and well being that you think may be useful

Client Policy Statement

Thank you for letting me be a part of your journey for better health and wellness.

Satori BodyCare can involve massage, dry needling, self-care techniques, stretching, floorwork and manipulations of the soft tissues and energy systems of the body. It can greatly reduce pain, increase range of motion, improve posture and functional movement, circulation and general well being. It is also known to decrease stress and improve sleep patterns.

Please note that I do not diagnose, prescribe or treat any kind of condition or disease. Anything done and said by a Massage Therapist must not be misconstrued as such, and is not to replace any medical advice and treatments.

Massage Therapy and dry needling, like any other health care technique has its own limitations and contraindications. For that reason, I will need to know precisely your state of health and/or any medication(s) that you may be taking. Any and all information concerning your health is strictly confidential and will not be released without your consent.

Payment for professional services is due at the time of service.

*A notice of no less than 24 hours must be given for cancellation of an appointment, or a charge of full payment will be due for the time reserved. Please note, that out of consideration for other clients, all sessions will end on time.

I also reserve the right to refuse service due to intoxication or uncleanliness.

Sexual innuendoes, offensive language and behavior will not be tolerated. Session will end immediately, and you will be charged full price.

As a client of Satori BodyCare, I have read and understand the above statements and I give full privilege and license to work on my body.

I hereby authorize, consent and certify by selecting "Submit" that I have completely read the above statements, understand them fully and agree to the above stated terms.