Date of Birth
Have you ever experienced professional massage or bodywork?
If yes, how recently?
Please carefully review this list and check those conditions that have affected your health either recently or in the past.
Describe the details of the items checked above
Please list any recent surgeries & past or current injuries
Please list current medications you are taking
Are you pregnant?
If yes, how many weeks are you?
If pregnant, how you been diagnosed as high risk?
If pregnant, what is your projected due date?
Do you have any of the following today?
Do you wear any of the following?(Please check all that apply)
What type of pressure do you prefer?
What are your goals/expectations for your session?
I understand the the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscle tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that pressure or strokes may be adjusted to my level of support,
I understand that massage/bodywork should not be construed as a substitute for medical diagnosis or treatment.
Because massage/bodywork should not be performed under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.
I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
Cancellation Policy: Our time together is important. We request 24 hours notice for cancelled appointments or pay the missed appointment fee in full.
Late Appointments: In order to uphold our professional standards of being on time, we regret that we cannot give additional time, if you arrive late for your appointment. If for some reason we are late starting your appointment, you will receive the full scheduled time.
Consent to Treat a Minor: I hereby authorize agents of Y'orbodi Kneads Spa & Wellness to administer massage/bodywork to my child or dependent (under 17).
Consent to Treat a Minor: Name of Adult/Guardian giving permission & relationship to client
How did you find us?