New Client Form

Please take a few minutes to fill out the form below prior to your first appointment. The information you provide will remain confidential. This form helps us appropriately prepare for our session. We appreciate your thoughtful and thorough answers.

Today's Date

YYYY

Name

First Name

Last Name

Phone Number

(###)

###

####

Birthdate

YYYY

How did you hear about The Self Sanctuary?

Have you ever received massage therapy before?

Any allergies/health history you'd like to share prior to your appointment?

Are you currently pregnant?

If you are pregnant, how many months will you be at the date of your appointment?

What's your reason for today's visit?

Are you currently treating any injuries?

If "yes," what injuries?

Are you currently experiencing any pain?

Rate severity of symptom areas from 1-10, 10 being the highest level of pain

Consent

By checking "Yes," I consent to receive massage therapy at The Self Sanctuary. I am aware of the benefits and risks of massage and give full consent to the session. I understand there is no implied or stated guarantee of success or 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 stated all medical conditions that I am aware of and will inform my massage therapist of any changes in my health status.

Electronic Signature