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Pink Feathers

New Client Intake Form

What is the reason for your visit today?

Massage

Lymphatic Drainage Post-Op Care

Lymphatic Detox

Body Treatment (Full Body Contouring)

Wellness Coaching

Is this your time getting a Massage or Lymphatic Drainage?

Yes

No

Referred by or How did you find out about us?

First Name

Last Name

Email

Cell No.

CONFIDENTIAL CLIENT INFORMATION AND HEALTH HISTORY

Address

Age

Gender

Male

Female

Emergency Contact Phone

Please select if you are, affected by or have any of the following conditions:

Neck/Spine Injury or Surgery

High Blood Pressure

Cold / Fever / Flu Symptoms

Pacemaker

Diabetes

current Rash

use Asthma Pump

Heart Condition (CHF)

Carpal Tunnel / Surgery

Herniated Disc

Rotator Cuff Surgery

Severe Eczema

Joint Swelling

Low Blood Pressure

Sinus

Back Pain

Sport Injuries

Smoker

Pregnant

Arthritis

Varicose Veins

Osteoporosis

Allergies

Kidney Disease

Lupus

Fibromyalgia

Bruise Easy

Numbness/Stabbing

Ankle Surgery

Cancer

Hysterectomy

Sciatica/Leg Pain

Headache

Hip Replacement

Stressed

Epilepsy/Seizure

Skin Disease

Hepatitis

Knee Surgery

Hormone Replacement

Open Sores

Athletes Foot

Large Fluid Retention or circulation issues

Deep Vein Thrombosis

ever had Chemo Therapy

Lipo - 360

Tummy Tuck

Full Body Lift

Arms or Thigh Lipo

Chin / Nose / Eye Augmentation

Breast Augmentation

Brazilian Butt Lift

Bra Roll or Armpits

Gastric Bypass

Radiation Burn /Previous Radiation Therapy

Have you ever done or any Ultrasound Cavitation or treatment?

Yes

No

List all Surgeries / Injuries ?

Main areas of concentration for your service?

POst Operative Care Manual Lymphatic Drainage (Date of Surgery and Location of Surgery)

Please list all Medications you are currently taking

Do I need to take extra precaution?

Open Incisions

Still Draining

Notice Sweet Smell on Skin

Navel Draining

Tight & Stiff

Have you ever had chemotherapy or Radiation burn after sugury

Yes

No

Have you had a chemical peel or any type of procedure with a medical device?

Yes

No

Have you recently had any type of Laser resurfacing

Yes

No

Do you have regular collagen, Botox or other dermal filler injections?

Yes

No

Are you allergic or sensitive to massage oils, creams, lotion, essential oils?

Yes

No

Is there any other diseases or disorders not listed above that we should be aware of?

Yes

No

I understand that massage therapists do not diagnose disease, prescribe medication, or manipulate bones. I further understand that massage therapist is not a substitute for medical attention or examination. Because massage therapy 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 take responsibility for alerting my practitioner to any physical, mental, or emotional changes that occur with my health and understand that shall be no liability on the practitioner's part should I forgot to do so.

I understand that not everyone is a candidate for this treatment and results may vary. I confirm that I have read and understand the above information and will undergo the treatment out of my own free will. I believe, I have adequate knowledge upon which to base an informed consent.

I understand that all remaining balance payments are due at time of service. No Show, No Call, No Refund. You have 24 yours to reschedule, or make changes to your reservations.

I understand that I am responsible for all charges. Prepaid packages once purchased is non-refundable. However, services not yet rendered may be canceled at least 7 days in advance less credit card and processing fees.

Cancellations must be done, 24 hours prior to the reserved appointment time, to avoid fee charges. By signing this document, I (you) understand that any illicit or sexual suggestive remarks advances will result in immediate termination of the session. I (you) affirm that all information provided above is correct to the best of my knowledge.

I consent to use Electronic Records and Signatures.

I consent to have pictures taken for the purposes of following my results, training, educational, and marketing.

Your Signature

Today's Date

Thanks for submitting!

1 Massage at a time LLC

WELLNESS FOR LIFE

Reservations

sharonsqs@gmail.com

337-454-5004 Office Line

© 2022 by 1 Massage at a Time LLC 3815 Kirkman St Lake Charles, LA | All Rights Reserved

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