Client Information And Consultation Form - Siena Massage printable pdf download

Client Information & Consultation Form

Name: __________________________________________________________ Date: __________________

Last

First

Address: __________________________________________________________________________________

Street

Apt

City

State

Zip

Cell Phone #: ________________________________ Mobile Provider: _______________________________

Used to text appointment reminders only.

E-Mail Address: ____________________________________________________________________________

Used for Siena Massage SPECIAL OFFERS! (Typically, only one per month.)

Date of Birth: _____________ How did you hear about Siena Massage? ______________________________

Any client under the age of 17 must have the written consent of parent or guardian to receive massage.

Yes

Have you had a professional massage before?

ow long ago? __________________________

What level of pressure do you prefer?

Very Light____ Light____ Medium____ Firm____ Very Firm____

Are you currently, or have you at any time within the last 12 months been under the care of a physician?

Please circle:

Yes

If so, for what condition(s)? ___________________________________________________________________

_______________________________________________________________________________________________________________

Are you currently pregnant?

Please circle:

Yes

If yes, which trimester? ___________________

Please list any medications you are currently taking: _______________________________________________

_______________________________________________________________________________________________________________

Please list any allergies you have: _______________________________________________________________

Please list any other medical conditions, illnesses, broken bones, surgeries, accidents or other relevant medical

conditions that you have had within the last three years:

___________________________________________________________________________________________

LIC # ME1459

Client Information And Consultation Form - Siena Massage