MASSAGE - DRAPER, UT
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Confidential Intake Form
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Name
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First
Last
Date of Birth
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Phone Number
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Email
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Emergency Contact Name
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Emergency Contact Phone Number
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How did you hear about Corner Canyon Massage Therapy?
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Have you had a professional massage before?
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Yes
No
If yes, how often do you receive massages?
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What type of massage are you seeking?
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Cupping Therapy
Deep Tissue / Therapeutic
Prenatal
Relaxation
List all surgeries, injuries, & accidents with year of occurrence (including known triggers for your pain or discomfort.)
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Are you currently under the care of a physician or health professional?
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Yes
No
For what conditions?
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Do you have allergies?
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Yes
No
Do you currently have any of the following health conditions?
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Blood Clots
Congestive Heart Failure
Contagious Diseases
Infections
Pitted Edema
N/A
If yes, what are you allergic to?
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Please list any other conditions that you have had or currently have.
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What is you occupation?
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What are your hobbies and regular physical activities?
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I love using essential oils during my treatments. I use only therapeutic grade ones. May I use them during your sessions?
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Yes
No
Consent for Treatment
I, the client, understand that the massage I receive is provided for basic purposes of relaxation and relief of muscular tension. I take full responsibility for informing my therapist of any condition that could effect this session. If I experience any pain or discomfort during my sessions, I will immediately inform the therapist so that the pressure and or strokes can be adjusted to my level of comfort.
I further understand that massage therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage therapy practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage therapy should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also 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. Understanding all of this, I give my consent to receive care.
Client Signature
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Date
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Corner Canyon Massage Therapy - 12441 S 900 E suite 255
Draper, UT 84020 - (303) 960-8616
Blog
Services
Rates
Appointment
Contact
About
Testimonials
Intake Form
CUPPING THERAPY RELEASE FORM
Insurance
Rock Tape
doTERRA
massage in Draper UT