Your Health Matters To Us

Please complete this survey to the best of your ability prior to your appointment.

We reserve the right to refuse service if this form has not been completed, in which case, same-day cancellation fees apply.

Confidential Client Record

Full Name *

Email *

Phone *

Address

Street Address

City

State

Country

Postal code

Date of birth *

Referred by a Friend/Other:

I Consent to Receive Email and/or SMS Notifications, Alerts & Occasional Marketing Communication from Calming Concepts. Message frequency varies. You unsubscribe at any time.

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Occupation/ Regular Sport/ Activities *

What is your intention for your treatment today? *

Medical History

Are you currently experiencing a struggle? *

Please rate your stress recently *

Low 1-3

Med 4-6

High 7-10

Are you currently being treated for any medical conditions? *

Are you taking any medications? *

Do you have any allergies to oils, fragrances or botanical ingredients? *

*

I understand that the treatments I receive at Calming Concepts is provided for the basic purpose of relaxation and relief of tension.

If I experience any pain or discomfort during the session I will immediately inform the therapist so that the pressure and/or techniques may be adjusted to my level of comfort.

I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment.

I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness.

Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered questions honestly.

I agree to keep my massage therapist updated as to any changes in my medical profile during the session and understand that there should be no liability on the massage therapists' part should I fail to do so.

I understand that the massage therapist reserves the right to refuse to perform treatments on anyone who deems to have a condition for which massage is contraindicated.

Your Initials *

Your Signature *

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Today's Date *

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