Intake Form

ARKANA MASSAGE & BODYWORK

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Intake Form
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Client Intake Form

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* Indicates required field

Client Name *

First

Last

Date of Birth *

Profession *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How did you hear about me? *

Google Friend Facebook Local Business Other

Have you had a professional massage before? *

Yes No

Please indicate if any of the following apply to you: *

Cancer Arthritis Joint Replacements Neuropathy Stroke Kidney Dysfunction Numbness Low Back Pain

Headaches/Migraines Diabetes High/Low Blood Pressure Fibromyalgia Heart Attack Blood Clots Sprains or Strains Mid Back Bain

Are any of the above that are checked controlled by medication? If yes, what kind? *

Do you suffer from chronic pain? If yes, please explain. What makes it better or worse? *

Do you have any orthopedic injuries? If yes, please list them and the dates of any surgeries: *

Do you have any allergies or sensitivities? If yes, please list them: *

Are there any areas (feet, face, hips, etc.) that you do NOT want massaged? *

Are you currently pregnant? If yes, how far along? Any high risk factors? *

What are your goals for this treatment session? *

What are your areas of discomfort or pain? *

Are you taking any medications? If yes, please list medications names and use: *

Is there anything in addition you would like to inform me about? *

By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. I am also agreeing to a general liability release giving permission to receive massage therapy. I have read and understand the cancellations and rescheduling policy located on the website. I understand that if I cancel within the 24 hours I will be responsible for 50% of the service and 100% for no show appointments. I understand that I or the massage therapist may terminate the session at any time. I understand that it is my duty to inform the therapist if I experience any discomfort at any time during the massage. I understand that the risks associated with massage therapy included superficial bruising, short term muscle soreness or exacerbation of undiscovered injury. Massage Therapy is not a substitute for traditional medical treatment or medications. *

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Availability
Wednesday-Saturday 12:00pm-8:00pm
Sunday 12:00pm-6:00pm
Closed Monday and Tuesday
By appointment only
No walk-ins
Same-day and out-hours appointments may be available upon request

Located in the building adjacent to Witt Chiropractic

Dalton Spradlin, LMT/NMT AL #4536
1915 Courtney Drive, Suite 3
Homewood, AL, 35209
(205) 705-9505
[email protected]

Proudly serving Birmingham and the surrounding area

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Client Intake Form

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Intake Form

FAQ & Policies