Away TBC New Client Information Online Form

ALL fields are required, unless otherwise stated. Please complete the entire form (4 parts)
and submit it at least 48 hours prior to your first appointment. Thank you very much.
All information is kept confidential.

PART 1: CONTACT INFORMATION

	PART 2: MEDICAL INFORMATION AND HEALTH HISTORY If you have a specific medical condition, or specific symptoms, massage therapy and body treatments may be contraindicated. Permission from your primary care provider may be required prior to service being provided. Please consider all areas of your health and be sure to include all current symptoms you are experiencing and present conditions you have been diagnosed with, as well as any past conditions. Please include dates and explain as clearly as possible.

			PART 3: ASSESSMENT INFORMATION

		PART 4: CLIENT AGREEMENT The following are some key client-practitioner matters that should be understood prior to scheduling an appointment. Please read each of the following and acknowledge that you have done so by checking the appropriate box. After you have reviewed the entire agreement, please sign, date, and submit only if you understand and agree with the each statement. If not, please feel free to contact me to discuss any questions or concerns that you may have!

				I have read, understand, and agree to comply with all of the stated POLICIES.

				My body hygiene will be suitable for receiving massage.

				I will be responsible for a payment of 50% of the Standard Rate for the time reserved for less than 12 hours notice of cancellation, and a payment of 100% of the Standard Rate for the time reserved for neglecting to show up for my appointment. I will pay this fee on, or before my next appointment.

				I understand that I need to arrive at least 5 minutes early to my scheduled appointment. If I am late for my appointment I understand that the session will have to end at the scheduled end time in order to accommodate the next client. There will be no compensation given for a late start and I am responsible for paying the full amount for the time reserved.

				I understand that any illicit or sexually suggestive remarks or advances made by me, the client, will result in immediate termination of the session, and unequivocal refusal of any further service by the practitioner. I will be responsible for payment in full for the scheduled appointment, and the local law authorities will be notified.

				I have stated all my known medical conditions and medications and supplements taken, and understand I am responsible to update the practitioner on my current state of health on all subsequent visits. I understand there shall be no liability on the practitioner’s part should I fail to do so.

				I understand the massage therapist does not diagnose illness, disease, or any other physical or mental disorder; does not prescribe medical or pharmaceutical treatment and does not do spinal manipulations. It is clear to me that massage is not a substitute for medical examinations and/or diagnosis, and it is recommended that I see a physician for any physical ailments. It is also clear to me that any information provided by the massage practitioner is for educational purposes only.

				It is my choice to receive massage therapy (or body treatments). I understand that the services provided are for the well being of my body and mind, and to enhance my body’ s natural healing processes. If I experience any pain or discomfort during a session, I will immediately inform the practitioner so that the pressure and/or techniques may be adjusted to my level of comfort. I agree to communicate with my practitioner any time I feel my well-being is being compromised.

Away Therapeutic Body Care

Confidential New Client Information Online Form

List, and briefly explain, ALL medical and health conditions the practitioner should be aware of (even if they are a very minor concern to you).

INCLUDE ANY PAST OR PRESENT ILLNESSES, INJURIES, PHYSICAL, EMOTIONAL, AND MENTAL CONDITIONS.

(Areas To Consider...
Circulatory System: Heart Conditions, low or high blood pressure, varicose veins, edema, etc.

Immune System: Hepatitis, HIV or AIDS, Herpes, Lymph Node Removal, etc.

Nervous System: Loss of sensation or paralysis, sensitivity to temperature, Sciatica, Insomnia, Frequent Headaches or Migraines, or Dizziness, etc.

Muscular and Skeletal System: Tendonitis, Bursitis, TMJ, Arthritis, Sprains, Strains, Osteoporosis, Herniated Disc, etc. 
 
Respiratory System: Asthma or Allergies, etc.

Digestive System: Ulcers, Loss of Appetite, etc.

Integumentary System; Skin: Fungal Infections, inflammation, warts, moles, rashes, lesions, bruise easily, etc.

Other Concerns: Diabetes, Any type of Cancer, Fatigue, Depression, Anxiety, and Alchohol, Nicotine, or Drug dependency.)

Please be sure to highlight and clear this entire section before entering your information.

PART 3: ASSESSMENT INFORMATION

CONSENT TO TREATMENT OF A MINOR: By my signature below I hereby authorize
Wendi Wells, Massage Practitioner to administer Massage Therapy or Body
Treatments to my child/dependant (age 17 or younger) as deemed necessary.

Tip: Please read each field carefully. Then,
highlight and clear the field before typing in
your information. Thank you.