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First and last name*
Mobile number*
Email address
Address
Apartment, suite or unit number
City
State
Postal code
Birthday*
Practitioner/Clinics : Sean LeeChong, LMT Purple Lounge Spa Mobile, LLC*
Contact Information:
Client Name:*
Date:*
Preferred phone number:*
Best time to call: 12noon - 2pm*
Email address:*
Preferred form of communication: Text then Call*
How did you hear about me? (referral, Facebook, etc.)*
Is this a gift certificate?
Yes
No
Have you had a massage/bodywork before?
Yes
No
Frequency:*
Types of massage/bodywork received:*
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?):*
Are you seeking insurance reimbursement?*
Yes
No
Car collision/personal injury?
On-the -job injury*
Private health insurance?*
Do you have a physician referral with diagnosis codes?
Best times for massage:*
Communication Checklist (Pt. 1)*
Fees/forms of payment
Cancellation/No-show policy
Late arrival policy
Confidentiality
Communication Checklist (Pt. 2)
Parking/directions
Work setting
Clothing/shiatsu
Communication Checklist (Pt. 3)
Modesty/Nonsexual/draping
Food/drugs/alcohol
Oils/lotions/allergies
Have you had a fever in the last 24 hours of 100°F or above?*
Yes
No
Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath*
Yes
No
Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?*
Yes
No
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?*
Yes
No
Do you have special needs I should prepare for:*
Do you have any questions or concerns:*
If out-call, ask for directions, parking, or special instructions:
Packet Checklist*
Health Information
Health Status Report
Billing Information
Directions/map
Date sent*
Additional Notes*