New Client Form - Advanced Holistic Healing Arts

Name*

First Last

Date*

Current Gender*

Male
Female
Other

Preferred Pronouns*

He/Him/His
She/Her/Hers
They/Them/Theirs

Date of Birth*

Phone*

Alternate Phone

Address*

Street Address Address Line 2 City State ZIP Code

Email*

referred by*

In case of emergency contact*

Emergency Phone*

In the event we need to contact you regarding an appointment, which would you prefer?*

Phone call
Text
email

Basic Health Information

Occupation

posture assumed most of the day

How often do you exercise?

Type of exercise

Height and Weight*

What are primary stressors*

job
family
finances
school
relationships
health
other

Are you basically in good Health

yes
no

Has there been any significant change to your health in the past year?*

yes
no

Are you happy with your general energy level?

yes
no

Do you use any of the following regularly?*

Please indicate if any of the following apply"*

List medications, herbs, drugs:*

What is your goal or concern for today's session?

Medial History

Indicate any of the following that apply in the last 6 months*

medication allergies*

Food allergies

lotion, cream, oil allergies*

Consents and Acknowledgments

Consent*

I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so.

Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I understand I may be asked for a referral from my primary care provider prior to service being rendered if determined necessary by my therapist.
I realize it is my choice to receive massage therapy. I acknowledge that the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, increasing circulation, energy or lymphatic flow, or increasing mobility.

Acknowledgement*

I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service.

I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations.

Release of Information*

I hereby authorize you to release to the practitioner named below any information necessary to provide the best care and collaboration.

I hereby authorize you to release to any physician or practitioner or the practitioner named below any medical or other records or information necessary to provide the best care and collaboration. These records are to be utilized for the coordination of care.

Name of Practitioner

Acknowlegment for Client and Practitioner Safety*

I agree to abide by any and all safety practices implemented by my therapist.

I have been informed of the precautions taken by my therapist to ensure a safe clean environment for my session. I have read the COVID-19 information found on this website. I realize I will be required to answer a series of questions before each session to ensure a safe session for myself and my therapists. I attest that my answers are truthful, trust my therapist to assess all the other clients for safety, and hold harmless my therapist in the event I contract COVID as a result of a session.

Financial Responsibility*

I agree to the financial policy.

I agree and acknowledge that I am responsible for payment of any balance due upon completion of each session unless prior arrangements are made. I understand that emergencies do arise that can result in missing an appointment. Please notify your practitioner as soon as possible if you will miss an appointment. There is no penalty for an infrequent late cancellation or missed appointment. If I fail to cancel two consecutive appointments, I will be responsible for payment of the full fee for both missed appointments prior to rescheduling another appointment.

New Client Intake Form

Basic Health Information

Medial History

Consents and Acknowledgments