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Form

First name(Required)

Last name(Required)

Phone(Required)

Is texting okay on this number?

Prefer texts only

Prefer texts calling okay

Prefer calls texting okay

Prefer calls only

Email(Required)

What type of session are you looking for?

Yoga

Massage

Both

Unsure

First time to Transcendence Massage & Yoga LLC?

Yes

Have you had a session before?

Yes (Massage)

No (Massage)

Yes (Yoga)

No (Yoga)

Referred to by Physician?(Required)

Yes

Looking for

Morning

Afternoon

Evening

Other

Wanting to book appointments on

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Wanting appointment

Within 1 week

Within 2 weeks

Within 3 weeks

Within 4 weeks

Longer than 1 month

Other

First Time Massage Clients

Transcendence Massage & Yoga LLC

First Time Massage Client Form

First name*

Last name*

Phone*

Birthday*

Month

Day

Year

Address

Have you ever had surgery?*

Have you ever had an accident?*

Long answer

Do you have any cardiac concerns?*

Aneurysms

Deep Vein Thrombosis

Heart Attack

High Blood Pressure

Any skin conditions?*

Eczema

Oral Herpes

Other Herpes

Psoriasis

Any neurological conditions?*

Seizures

Stroke

Any implanted medical devices?

Long answer

Currently experiencing feelings of illness?*

Gastrointestinal conditions?*

Coeliac Disease

Hernia

Parasitic Disease

Ulcers

any other health conditions not covered in form

Disclosure:

By checking this box I agree that I have listed all medical conditions to the best of my knowledge. If found that I have misrepresented any health conditions which leads to a complication I agree to hold myself, not Transcendence Massage & Yoga LLC, liable.

By checking this box I agree that I understand that the massage I receive is provided for the basic purpose of relieving muscular tension, relieving pain and facilitating range of motion and relaxation. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

By checking this box I agree that I understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

By signing this form I confirm my consent to treatment. In addition, I intend this consent to cover the treatment discussed with me and such additional treatment as performed by my massage therapist from time to time to deal with my physical condition for which I have sought massage therapy. I understand that at any time I may withdraw my consent and massage therapy will be stopped.

Signature*

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Date*

Month

Day

Year