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New Client Intake Form

Please take your time to fill out the intake form which is needed prior to your first appointment!

Client Intake Form
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Contact Information

Mandatory to fill out*

Gender
Date of Birth
Month
Day
Year

Emergency Contact Information*

Mandatory to fill out*

Doctor Information (Optional)

Issues to Address Information*

Mandatory to fill out*

Existing Conditions Information

Respiratory
Cardiovascular
Skin
Head and Neck
Infectious Conditions
Women
Soft Tissue / Joint Dysfunction
Family History
Miscellaneous
Neurological

Client Waiver Form

Please take a moment to read and initial the following information:


I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. I affirm that I have notified my therapist of all known medical conditions and injuries. I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. I understand that massage is entirely therapeutic and non-sexual in nature. I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

After agreeing, please sign below:
I have read the statement above and agree to all the policies.
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Mobile Massage Services in Monmouth County, NJ by Appointment Only

On-Site Massage Services by Appointment Only

New Client Intake Form

 

39 Main Street, Bradley Beach, NJ 07720

Charles@RogersHandsOnTherapy.com | (732) 407-2076

Rogers Hands-On Therapy Massage

Copyright © 2024 Rogers Hands-On Therapy, LLC - All Rights Reserved.

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