Intake form

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ABOUT US
SERVICES AND RATES
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Intake form
CONTACT US

Home
ABOUT US
SERVICES AND RATES
BLOGS
Intake form
CONTACT US

832-758-8050

bodyexhale@yahoo.com

Home
ABOUT US
SERVICES AND RATES
BLOGS
Intake form
CONTACT US

Home
ABOUT US
SERVICES AND RATES
BLOGS
Intake form
CONTACT US

832-758-8050

bodyexhale@yahoo.com

Please fill out this intake form before your first session with Body Exhale Mobile Massage Therapy.

Intake Form Fluent 1

Today's Date

Date Of Birth

Name

Street Address

City

State

Zip Code

Home #

Mobile #

Occupation

What type of healthcare are you receiving? (physician, chiropractor, acupuncturist, e.t.c.)

Do you have, or have you had in the past, any of the following conditions: (This information is strictly confidential and may be very important to your therapy.)

Diabetes

Injuries

Inflammation

Arthritis

Skin Issues

Surgery

Varicose Veins

Spinal Injury

Headaches

Numbness or tingling

Allergies (skin, scent, nuts, etc)

Heart Condition

Athlete's foot

Other

Explain Other

Have you been ill recently?

Yes

Any cough or fever in the last week?

Yes

Previous massage / bodywork experience:

Never

Occassionally

Often

If so, what type of bodywork have you had?

What are your areas of pain or discomfort?

Type of massage you are requesting? ( Please select one or more below)

Swedish/Relaxation

Deep Tissue

Pregnancy Massage

Post- op Lymphatic Drain

Geriatric Massage

Sports Massage/Stretching

Please list any medications you are taking.

Please list any surgeries, major accidents or serious injuries within the last 3 years.

Are you pregnant?

Yes

"I understand that massage therapy involves neither diagnosis nor treatment of any condition and is not a substitute for medical care. The session is a full body massage that includes the face, feet, and gluteus. Draping of the genital area and gluteal cleavage will always be used for all clients. The licensee shall drape the breasts of all female clients and not engage in breast massage of all female clients unless the client gives written consent before each session involving medical breast massage. If I or the therapist become uncomfortable for any reason, either person may request to end the session, and the session will be ended. Licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature."

I may itemize here any areas of my body which I wish to be avoided, and these will be avoided. (scalp, face, feet, etc.)

I hereby give permission for manual lymph drainage (MLD) to the breast area. (Post operation clients only)

Yes

The cancallation fee is 50% of any appointment rate if cancelled less than 24 hours before appointment time. Body Exhale confirms appointments with all clients 24 hours before the arranged session.

Please type your signature below and click the Send Button at the end of the form. Clicking the Send button means you have agreed to everything above.

If you are a new client: How did you find Body Exhale?

Referral from a Friend

Corporate Referral

Online Search

Referral Name

To be filled out by licensee:

Type of massage service/technique to be used:

Parts of the body to be massaged:

Therapist Signature:

Today's Date

Date Of Birth

Name

Address

City

State

ZIP

Home #

Mobile #

Occupation

What type of healthcare are you receiving? (physician, chiropractor, acupuncturist, e.t.c.)

Do you have, or have you had in the past, any of the following conditions: (This information is strictly confidential and may be very important to your therapy.)

Diabetes Injuries Inflammation Arthritis Skin Issues Surgery Varicose Veins Spinal Injury Headaches Numbness or tingling Allergies (skin, scent, nuts, etc) Heart Condition Athlete's Foot Other

Explain Other

Have you been ill recently?

Any cough or fever in the last week?

Previous massage / bodywork experience:

If so, what type of bodywork have you had?

What are your areas of pain or discomfort?

Type of massage you are requesting? ( Please select one or more below

Swedish/Relaxation Deep Tissue Pregnancy Massage Post- op Lymphatic Drainage Geriatric Massage Sports Massage/Stretching

Please list any medications you are taking.

Please list any surgeries, major accidents or serious injuries within the last 3 years.

Are you pregnant?

Massage Therapy Information

I understand that massage therapy involves neither diagnoses nor treatment of any condition and is not a substitute for medical care. The session is a full body massage that includes the face, feet, and gluteus. Draping of the genital area and gluteal cleavage will always be used for all clients. The licensee shall drape the breasts of all female clients and not engage in breast massage of all female clients unless the client gives written consent before each session involving medical breast massage. If I or the therapist become uncomfortable for any reason, either person may request to end the session, and the session will be ended. Licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature.

I may itemize here any areas of my body which I wish to be avoided, and these will be avoided. (scalp, face, feet, etc.)

I hereby give permission for medical breast massage.

Yes No

The cancallation fee is 50% of any appointment rate if cancelled less than 24 hours before appointment time. Body Exhale confirms appointments with all clients 24 hours before the arranged session.

Please type your signature below and click the Send Button at the end of the form. Clicking the Send button means you have agreed to everything above.

If you are a new client: How did you find Body Exhale?

Referral from a Friend Corporate Referral Online Search

Styled HR

Text Size Example To be filled out by licensee:

Type of massage service/technique to be used:

Parts of the body to be massaged:

Therapist Signature:

About Us

Body Exhale Mobile Massage Therapy is owned and managed by Heather Guidry, LMT, who is a respected therapist in her field. Her practice has been in business for over 20 years and services a wide variety of clients.

Body Exhale travels to your home, office or place of lodging and provides a massage experience tailored to your individual needs.

License Number MT-045604

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bodyexhale@yahoo.com

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