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1Massage @ aTime, LLC

New Client Intake Form

Select the reason for your visit *

Massage (Therapeutic)

Lymphatic Drainage | Post-Surgery

Lymphatic Detox |Non-Surgery

Body Treatment (Calvitation Contouring)

Health Consultation | 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

Gender *

Male

Female

Age

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

Health Wellness Prgm

Heart Condition (CHF)

Carpal Tunnel / Surgery

Herniated Disc

Rotator Cuff Surgery

Severe Eczema

Joint Swelling

Low Blood Pressure

Sinus

Back Pain

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

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

Sweet Smell on Skin

Tight & Stiff

Have you ever had chemotherapy or Radiation burn after sugery *

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 to reserve my appointment. If I, No Show, I will not receive a refund. I will give a 24 notice to allow enough time to fill my slot. I am aware that I can reschedule, or make changes to my reservations.

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

Thanks for submitting!

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1 Massage at a time LLC

WELLNESS FOR LIFE

337-302-0877 Office Line

© Revised 2024 by 1 Massage at a Time LLC 3815 Kirkman St Lake Charles, LA | All Rights Reserved

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