New Client Intake formPlease fill out the intake form which will help guide our session. Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * Referred By Preferred Pronouns Emergency Contact/Phone Number Are there any areas you would like me to avoid? What are your goals for our session? Specific areas you want worked on? Please list any current medications and their purposes Please list any allergies Please list any injuries and/or surgeries and their dates Please check any that apply Headaches/migraines Joint stiffness/swelling Jaw pain Bursitis Scoliosis Arthritis Planta Fasciitis Lymphedema IBS Dizziness/fainting Varicose Veins Blood Clots Heart Condition Low/High Blood Pressure Pregnant Endometriosis Numbness/tingling Restless Leg Syndrome Siezures Fibromyalgia Cancer Diabetes Depression Anxiety Contagious Skin Condition Drug Use Please list any conditions not listed above. If there are any other information you would like me to know, please share. Cancellation Policy and Informed Consent to Receive Massage * Cancellation Policy and Informed Consent to Receive Massage and Bodywork (Copy) It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. I have completed this form to the best of my ability and I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. By checking "I have read and agree to the terms above," I agree to waive all liabilities toward Chariot Massage and Bodywork LLC for any injury or damages incurred due to any misrepresentation of my health history. I have read and agree to the terms above. Please give 48 hours notice to cancelling or rescheduling an appointment. Cancellations less than 48 hours will be charged 50% of the service fee, anything under 24 hours will be charged the full service fee. No shows will be charged the full service fee. * I understand and agree to the cancellation policy. Thank you!