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Remedial Massage Client Intake Form

 

If this is your first time coming to Clarity Massage & Wellness for a Remedial Massage session (or you have been instructed to by one of our staff members), you will need to complete this form before your session. To save time, complete it now.

    Your Details





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    Emergency Contact



    Medical History


    Do you frequently suffer from stress? YesNo

    Do you experience frequent headaches? YesNo

    Do you suffer from arthritis? YesNo

    Do you have high blood pressure? YesNo - If yes, are you taking medication? YesNo

    Do you suffer from epilepsy or seizures? YesNo

    Do you have varicose veins? YesNo

    Do you have any contagious diseases? YesNo
    Do you have any allergies? YesNo
    Do you have cardiac or circulatory problems? YesNo
    Do you have numbness or stabbing pain? YesNo
    Are you sensitive to touch or pressure anywhere? YesNo
    Are you pregnant? YesNo
    Do you have diabetes? YesNo

    Do you wear contact lenses? YesNo

    Do you suffer from joint swelling? YesNo

    Do you have osteoporosis? YesNo

    Have you been diagnosed with cancer? YesNo

    - If yes, have you received permission from your health care provider to receive treatment? YesNo

    Please click the relevant number that indicates what sort of pressure you like in a massage (your practitioner will discuss this and check in with you during treatment):
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    Please list any recent (2 years) injuries or medical conditions, including surgery:
    Please list any regular sport, exercise or manual labour you participate in:
    Please list all medication or supplements you are taking:

    Please tell us the area/s of tension, pain, soreness or injury:
    Is this issue affecting your: Sleep?Lifestyle?Work?State of mind?

    What do you hope to achieve through massage?

    Client Waiver

    I understand that the massage I receive is provided for the purpose of relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure may be adjusted to my level of comfort.

    Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, & answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile & understand that there shall be no liability on the practitioner’s part should I fail to do so.

    I understand and agree to the Clarity Late Notice Policy: that a $50 fee applies for any missed appointments or cancellations made within 24 hours.


    I accept the conditions in the above client waiver and consent to receiving treatment at Clarity Massage and Wellness.




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