Mobile Massage - Intake Form Mobile Massage is available upon request ONLY. Fill out the Mobile Massage Intake Form form below and Joyful Bodies Massage will contact you soon to schedule an appointment. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date Of Birth * MM DD YYYY Occupation Emergency Contact Person * Emergency Contact Phone # * (###) ### #### Are you currently under a physicians care for an acute or chronic illness? * Yes No If yes, please explain: Are you taking any prescribed medication(s) or dietary supplements? * Yes No If yes, please explain: Have you received a massage before? * Yes No How did you hear about Joyful Bodies? * What are your goals for this session? Checkbox * Abdominal /digestive problems Allergies Anxiety Arthritis/tendonitis Asthma or lung cond. Athletes foot Blood clots Chronic pain Circulatory/heart problems Constipation/diarrhea Depression Diabetes Fatigue Headaches, migraine Hearing problems Hernia High blood pressure Jaw pain/TMJ pain Low blood pressure Muscle/bone injuries Muscle/joint pain Numbness/tingling Pregnancy Rash/fungus Sinus problems Sleep difficulties Spinal disorders Sprain/strain Tension/stress Vision problems Varicose veins Please list any recent injuries or surgeries within the past 5 years: Please type name as your signature & acknowledgement below: * I have stated all conditions that I am aware of and this information is true & accurate to the best of my knowledge.I will inform my massage therapist if anything changes in my status. I understand that massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension, spasm, or pain and to increase circulation. If I experience any pain or discomfort, I will immediately inform my massage therapist so that the pressure and/or methods can be adjusted to my comfort level. I understand that my massage therapist does not diagnose illness or disease, nor perform any spinal manipulations. and does not prescribe any medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services. If I am unable to attend my scheduled appointment, I will respect and abide by the set cancellation policies. Sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated. I understand that I am receiving massage therapy at my own risks. In the event that I become injuries either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever. First Name Last Name Date Of Signature ? * MM DD YYYY COVID-19 Policy * Covid-19 as an infectious virus that currently has no direct treatment and for which there is no current vaccine. While we have taken reasonable steps to limit the potential for transmission of COVID-19 in our studio, you agree that you understand that transmission of COVID-19 is still possible. By necessity, massage therapy requires that our therapist is within 6 feet of you and will need to touch you and the potential chance of COVID-19 transmission. It may be necessary that you quarantine and/or take other steps in the event it is determined that you may have been exposed to COVID-19 are subject to modifications. I understand the COVID-19 situation and assume all risks associated with treatment during this time. Thank you!
