Touch of Heaven Massage

Name*

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Address

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Phone Number

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Emergency Contact

Emergency Contact Phone Number

Occupation

Age

Physician

Have you ever had a professional massage or bodywork session?

Yes
No

If "Yes" how recently?

What kind of massage/bodywork?

What is your primary complaint today?

When did you first experience this condition?

What makes it worse?

What makes it better?

Have you sought other remedies for this condition?

Yes
No

If "Yes" specify

Physician
Chiropractor
Physical Therapist
Complementary Medicine

Are you taking any medication (include herbs and vitamins)? List and explain purpose.

List any surgeries that you have experienced

Please check all that apply

Terms and Conditions

Cancellation Policy

I request that if you need to cancel your appointment, please do so 24 hours in advance. Missed appointments and "no shows" will be charged a full fee.

Lateness Policy

I request that you arrive early for your appointment. I cannot give you additional time if you arrive late. If for any reason I am late starting your appointment, you will receive the full scheduled time.

Massage is strictly non-sexual

Massage sessions are strictly non-sexual. Any suggestive statements or actions will result in immediate termination of the session wherein the client pays the full cost of the session. Law enforcement will be notified if deemed appropriate.

Please take a moment to carefully read the following information

I understand that massage is not a replacement for medical care and that no diagnosis will be made. (If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided).

I am responsible for paying for any appointment cancellation of less than 24 hours.

I am responsible for full payment at time of service.

I understand that all information is strictly confidential and will only be released upon my written request.

*

I have read and agree to all terms and conditions