Erin’s Massage Therapy Client Information Form
Instructions
Print this form. Fill out all applicable information and call Erin Martin at (505) 730-9523 to set an appointment.
Name _____________________________________________
Street. Add. ________________________________________
City ________________________ ST _____ Zip ___________
Occupation _______________________________
Referred By ________________________________________
Birth Date _______________________
Telephone # _____________________
Business # _____________________
Cell # ______________________
SSN ___________________________
Have you received Therapeutic Massage? Yes ___ No ____ If so, how often? ____________
What is the reason for your visit today? __________________________________________________
Are there any areas you want me to concentrate on?______________________________________
Do you prefer a deep or light massage?_______________ Do you like stretches?_____________
Are there any areas you wish not to treat?_______________________________________
Are you under the care of a physician or other health care practitioner?_________
If yes, for what?__________________________________________________________________
Are you pregnant? __________
If yes, what trimester?________
Are you having any problems that I should know about? _________________________________________________
If so, do you have a doctor’s consent?___________________________________________________
Are you having any problems that I should know about? _________________________________________________
If so, do you have a doctor’s consent?___________________________________________________
Do you want your abdomen massaged? _____________ Around Breast?_______________________
List any medications you are now taking and what they are used for: _________________________
Please check off any of the following conditions or symptoms which apply to you now or in the past:
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____Allergies
____Recent Illness, Injury or Surgery
____Areas of Pain
____Contagious Condition/Disease
____Osteoporosis or Osteopenia
____Occupational Injury
____History or Treatment of Cancer
____Lymph Edema
____Kidney Problems
____Doctor’s Care
____High Blood Pressure
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____Cardiac or Circulatory Problems
____Headaches
____Diabetes
____Epilepsy or Seizures
____Bruise Easily
____Chronic Fatigue
____Active Cancer
____Swelling
____Pregnancy
____Medications
____Low Blood Pressure
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____Vein Problems
____Joint Problems
____Arthritis
____Broken Bones
____Stress
____Fibromyalgia
____Active Infection
____Liver Problems
____Abdominal Issues
____Other concerns
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This massage is for therapeutic purposes only and completely NON-SEXUAL. Your cooperation is expected.
I understand the massage services are designed to be a health aid and are in no way to take the place of a doctor’s care when it is indicated. Information exchanged during any massage session is educational in nature and is intended to help you become more familiar and conscious of your own health status and is to be used at your own discretion.
CANCELLATION POLICY: A 24 hour cancellation notice is required. If I do not receive 24 hour notice you will be sent a bill for the missed appointment, and in the future you will be required to give a credit card when booking your appointment.
Your appointment time has been set aside especially for you. If you are unable to keep the appointment, then there must be enough notice given so others who are waiting have the opportunity to reserve that time.
Name (signature) _________________________________________ Date _____________________
Emergency Contact:______________________Phone________________Relationship_____________