Bowen Breath Works & Massage
Client Information Form
Instructions
Print this form. Fill out all applicable information and
call Greg Anderson at (505) 489-3903 to set an appointment.
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Name _____________________________________________ Street. Add. ________________________________________ City ________________________ ST _____ Zip ___________ Occupation ___________________Marital Status? ________ |
Birth Date _______________________ Telephone # _____________________ Business # ______________________ SSN ___________________________ |
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Have you received Therapeutic Massage? Yes ___ No ____ If so, how often? ____________ What is the reason for your visit today? __________________________________________________ Are there any areas you want met to concentrate on?______________________________________ Do you prefer a deep or light massage?_______________ Do you like stretches?_____________ Are there any areas you want to avoid being treated?_______________________________________ Are you under the care of a physician or other health care practitioner?_________If yes is indicated, for what?__________________________________________________________________ Are you pregnant? __________ If yes is indicated, what trimester?________ If yes, are you having any problems that I should know about? _________________________________________________ If so, do you have a doctor's concent?___________________________________________________ Do you want your abdomen massaged? _____________ Around Breast?_______________________ List any medications you are now taking and what they are used for: _________________________ |
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| Please check off any of the following conditions or symptoms which apply to you now or in the past: | |||
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serious injuries ____ blood clots ____ allergies ____ high blood pressure ____ contagious conditions ____ AIDS ____ stroke |
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headaches ____ low blood pressure ____ skin infections ____ heart attack ____ recent surgery ____ arthritis ____ varicose veins |
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back pain ____ use of tobacco ____ contacts ____ diabetes ____ allergy to perfumes or oils ____ other |
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This massage is for therapeutic purposes only and completely NON-SEXUAL. Your cooperation is expected. I understand the massage services are designed to be a health aid and are in no way to take the place of a doctor's care when it is indicated. Information exchanged during any massage session is educational in nature and is intended to help you become more familiar and conscious of your own health status and is to be used at your own discretion. CANCELLATION POLICY: A 24 hour cancellation notice is required. If I do not receive 24 hour notice you will be sent a bill for the missed appointment, and in the future you will be required to give a credit card when booking your appointment. Your appointment time has been set aside especially for you. If you are unable to keep the appointment, then there must be enough notice given so others who are waiting have the opportunity to reserve that time. Name (signature) _________________________________________ Date _____________________ Emergency Contact:______________________Phone________________Relationship_____________ If you would like to receive notification of specials please give me your email address: __________________________________________ |