First and last name*

Mobile number

Email address

Client Full Name:*

Date (mm/dd/yyy):*

Preferred phone number:*

Does Blink and Breathe Bodywork have your permission to text and/or email you appointment information? *

Email address:*

Preferred form of communication:

How did you hear about me? (referral, Facebook, etc.)*

Is this a Groupon or gift certificate?*

Have you had a massage/bodywork before?*

Desired Frequency? (Weekly, Monthly)*

Preferred types of massage:*

Reasons for seeking massage? (relaxation, injury, etc.)*

Description of injury/health condition:*

Possible complications/medications:*

Expected outcomes (functional improvement, symptom relief, wellness):

Typical activities of daily living (affected by condition?):

Occupation (affected by condition?):

Best times for massage: (AM, Mid-day, Evenings)

Have you had a fever in the last 24 hours of 100°F or above?*

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath*

Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?*

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*

Do you have special needs I should prepare for:*

Do you have any questions or concerns:

Date sent*