Intake Form Intake FormFirst NameLast NameDate of BirthEmailService Location (Home or Short Rental)Location Additional Information (Apt, house #, business, etc.)Emergency Contact NameEmergency Contact PhoneMusic Preference- Select -InstrumentalNatureRelaxationPressure Preference- Select -DeepMediumLightGeneral Medical Information Joint Problems Headache Sensitive Skin High Blood Pressure Heart Conditions Asthma Recent Surgery Diabetes Anxiety Allergies Pregnant Breast FeedingList any other condition(s) that can prevent you from receiving therapy (we recommend proceeding only with doctor's approval if necessary)Mark any areas where you feel pain or discomfort (see image below)Front (left) Neck Shoulder Chest Bicep Forearm Oblique Abdominal Quadricep CalveFront (right) Neck Shoulder Chest Bicep Forearm Oblique Abdominal Quadricep CalveBack (left) Upper Back Shoulder Tricep Middle Back Forearm Lower Back Glute Hamstring CalveBack (right) Upper Back Shoulder Tricep Middle Back Forearm Lower Back Glute Hamstring CalveSee image below for reference Submit Form
