New ClientS 

Name *

First Name

Last Name

Phone Number

(###)

###

####

Date *

MM

DD

YYYY

Date of Birth *

MM

DD

YYYY

Have you experienced a professional massage in the past? *

Yes

No

Do you experience frequent headaches? *

Yes

No

Are you pregnant? *

Yes

No

Do any of the following conditions apply to you? Check all that apply *

diabetes

high blood pressure

epilepsy or seizures

varicose veins

allergies

cardiac or circulatory issues

cancer

arthritis

none of these

Any injuries in the past two years? *

Yes

No

Any broken bones in the last two years? *

Yes

No

Do you have any numbness or stabbing pains? *

Yers

No

Have you ever had surgery? Explain below *

Yes

No

Any other medical condition, or are you taking any medications that I should know about? *

Yes

No

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the practitioner so that the pressure and/or techniques may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified specialist for any mental or physical ailment of which I am aware. I understand that my massage/bodywork practitioner is a licensed massage therapist and is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of my session should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part or that of Unbounded Massage + Wellness should I fail to do so. 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. *

I understand & agree to these terms