Patient Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
*
Emergency Contact Name
*
First Name
Last Name
Emergency Phone
*
(###)
###
####
Relation to Patient
*
Have you ever experienced a massage before?
*
Yes
No
What is the main reason for your massage?
*
Why did you choose Under Pressure Massage?
*
Have you ever received massage therapy?
*
Yes
No
If yes, what type of therapy?
Please list all of your current medications
*
Are you currently pregnant?
*
Yes
No
If yes, how far along is your pregnancy?
What is the due date for your child?
MM
DD
YYYY
Where are you experiencing pain?
*
If other, describe your pain here
How severe is your pain on a scale of 1-10?
*
1
2
3
4
5
6
7
8
9
10
Have you suffered any of the following injuries?
Please provide details about your injuries:
Do you currently have cancer or have had cancer in the past?
*
Yes
No
If yes, please explain what type of cancer
Do you currently have any of these conditions?
Please provide any additional information about your current conditions
Have you ever experienced a Mastectomy or Breast Augmentation?
*
Yes
No
If yes, please explain
Do you have any of the following today?
Do you have any skin allergies?
*
I understand that this massage is not a replacement for medical care and that no diagnosis will be made. It is recommended that I see a physician for any physical ailment that I may have.
*
I understand that massage therapists do not prescribe medical treatments or pharmaceuticals, and does not preform any spinal adjustments.
*
I am aware that if I have any serious medical diagnosis, I must provide a physician's written consent prior to services.
*
I understand that draping will be used on ALL areas not being treated. If the client or therapist is uncomfortable for any reason, the clients or therapist may ask to end the session, and the session will be ended.
*
I understand that I will be responsible for any payment of $40 for any unapproved cancellations
*
I COMPLETLY UNDERSTAND THAT UNDER PRESSURE MASSAGE IS A ZERO-TOLERANCE ESTABLISHMENT. IN UNDERSTANDING THIS, I WILL NOT MAKE JOKES, INNUENDOS, OR INAPPROPRIATE TOUCHING, SEXUAL REQUESTS OR SOLICITATIONS OF ANY KIND. IF I DO SO, I UNDERSTAND THE SESSION WILL BE TERMINATED AND MY INFORMATION WILL BE HANDED OVER TO POLICE
*
