Date:*

First and last name*

Mobile number*

Email address*

Address

Apartment, suite or unit number

City

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

Have you had a massage therapy / bodywork before?*

Description of injury/health condition:

Car collision / Personal injury? *

On-the-job injury (L&I)?*

Will we be billing private health insurance? If yes, please fill in Health Practitioner information*

Health Practitioner/ Clinic Name:

Health Practitioner / Clinic Contact Information:

Do you have a physician referral with diagnosis codes?

Do you currently have any health condition that is contagious or transmissible? Example conditions: cellulitis, HIV, flu, shingles, ringworm, hepatitis A/B/C, lesions, or other? If so, please list.*

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:

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

Is this a gift certificate? If yes, please indicate here and provide gift certificate number at your scheduled appointment*

Additional Notes