Client Information Form

Please provide us with the following information so that we may serve you better.

Age:

Spouse:

# of children:

******************************************************************************

So we may serve you better, please indicate if you currently or have been diagnosed with any of the following:

******************************************************************************

For what condition?

List anything that makes your condition worse:

Please list current medications and their use:

Have you had surgery in the past few years?  If so, explain:

Please list any injuries or accidents and when they occurred:

Regarding our aromatherapy, do you know if you have any allergies to plant extracts?

Have you ever had a therapeutic massage? Y    N  

If so, How long ago?  

What is your main objective for receiving therapeutic bodywork today? 

Additional comments concerning your health or needs:

***************************************************************************

***************************************************************************

Insurance Information:

 Company Name:

 Address:

 Phone #:

Insured SSN#:

Group #:

Insured's Name:

Relationship:

Insured's Employer:

All information is confidential, unless we receive a signed authorization from the client for release of information.

Payment is due when services are rendered, unless other arrangements have been made.

With respect to our scheduling demands and our other clients' needs, we reserve the right to charge for cancellations made without a 24-hour notice!!

Thank you for allowing us to serve you!