Massage: New Client Profile & Waiver Name * First Name Last Name Email * Address * Street, Town, State, Zip Date of Birth * MM DD YYYY Phone * (###) ### #### Are you able to receive text messages? * Occupation * Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### How did you hear about Amanda Meyer, LMT? * Reason for initial visit: * Have you ever received a professional massage? * Yes No If yes, when was your last treatment? Have you ever had an form of cupping therapy? If yes, explain your treatment. * Type "NO" if you have never had cupping therapy before. Health Questionnaire * Check any that apply. Headaches/migraines Vertigo/dizziness Ringing in ears Asthma Shortness of breath Chronic cough Congestion Frequent Colds Sensory loss/change Seizures/Epilepsy Numbness/tingling Sciatica Multiple Sclerosis Arthritis Osteoporosis Tendonitis Bursitis Jaw pain (TMJD) High/Low Blood Pressure Heart Attack Stroke Poor circulation Blood clots Varicose veins Hardware Skin infection or conditions History of car accident Whiplash or concussion Muscle/ligament/tendon injuries Broken bones History of cancer Depression Anxiety Digestive conditions Fibromyalgia Carpal tunnel Tennis or golfer's elbow Other: If you selected other, please describe: Are you currently pregnant? * Yes No If pregnant, how far along are you? * Please type "N/A" if not applicable. If pregnant, are you considered high risk? * Please type "N/A" if not applicable. List current medications and the conditions they are treating: * Type "NONE" if this doesn't apply. List any major accidents or surgeries, including dates if possible: * Type "NONE" if this doesn't apply. In this section, please describe any additional health concerns, history, medications, or other factors that could affect your work with me. * Type "NONE" if this doesn't apply. 24 HOUR CANCELLATION POLICY As a courtesy to others, I understand that if I cancel a scheduled appointment within less than 24 hours notice I will be held responsible for the appointment fee. Typing my name below acts as my signature. Massage Therapy Waiver & Release * It is my choice to receive massage therapy under the care of Amanda Meyer, LMT. I am aware of the benefits and risks of massage and cupping and give my consent for massage or cupping therapy. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by various care providers involved in my care and treatment. Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage. Typing my name here acts as my signature. Today's Date MM DD YYYY Thank you! Amanda will get in touch with you soon!