Massage Intake form

Please fill out the following form prior to your first MASSAGE with Serendipity Wellness Studio, if it has been over 1 year since your last massage with us, or if you have had any major health changes

Appointment date

First Name

Last Name

best contact ph#

birthdate

house# and street

city, state, zip

emergency contact name

emergency contact phone

occupation

Whom may we thank for referring you

Any injuries in the past 72 hours?

Yes

If you answered yes to any question, please elaborate

Please all medications/supplements currently taking

Please let us know about any other medical condition or anything else you think is important for your therapist to know

Please let us know about the reason for your visit today. What issues do you want to address and what are your goals for today's appointment?

Informed Consent: The above information is accurate and complete. To the best of my knowledge, my health is appropriate for massage therapy or bodywork. I agree to inform the therapist of any pain experienced during the massage session. I understand that since massage is contraindicated in some medical conditions, that it may be necessary to obtain a doctor’s release prior to beginning therapy. I understand that massage therapy should not be considered a substitute for medical examination, diagnosis or treatment, and that I should see a medical or chiropractic physician or other healthcare specialist. The massage therapist is not a doctor and cannot provide medical treatment, nothing said in the course of the session should be construed as such. I agree to update the massage therapist in regard to changes in my health and understand that there shall be no liability on the therapist’s part should I forget to do so. I agree to hold harmless Serendipity Wellness Studio, Jennifer Ferdinand and any employees or independent contractors from and against any and all claims

We are so glad you chose to come see us today. We want to do our best to ensure you have a wonderful experience with us today. Please help us to help you. • Let your therapist know what brings you in today. If you are having aches and pains and where. Let us know specifically what you are looking for and areas you would like to focus on, if any. • Speak up and let your therapist know if something is not feeling good. – we cannot read your mind and cannot always accurately interpret your non-verbal cues. Please SPEAK UP and let us know if we need to adjust something. DO NOT SUFFER IN SILENCE. • Please let us know if there is anything we can do to make you more comfortable. Are you chili? Too warm? Would another pillow make you more comfortable? Do you not like one of the essential oils we are using? Please let us know, so we can adjust things to your liking. • You have control over your experience with Serendipity Wellness Studio. I will verbally let my therapist know if I would like something adjusted during my service. I will not rely on non-verbal cues.

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Thanks for submitting! We are looking forward to seeing you!

5252 Lyngate Court Suite 202
Burke, Va. 22015
571-217-1150
info@serendipitywellnessstudio.com

Save time- complete your new client intake forms ahead of time.

Massage Intake form