Services
About Nicole
Connect & Book
Services
About Nicole
Connect & Book
Nicole Phillips, Certified Massage Therapist
Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of birth
*
MM
DD
YYYY
Referred by
Emergency Contact Person
*
Phone (Emergency Contact)
*
(###)
###
####
What is your reason for seeking massage?
*
Any other areas needing attention?
*
Are you experiencing pain, soreness, or tension in any of the following areas?
*
Check all that apply.
Head
Jaw
Neck
Shoulder (L)
Shoulder (R)
Arm (L)
Arm (R)
Wrist (L)
Wrist (R)
Upper Back
Mid-Back
Low Back
Chest
Abdomen
Calves (L)
Calves (R)
Thigh (L)
Thigh (R)
Knee (L)
Knee (R)
Ankle (L)
Ankle (R)
Hip (L)
Hip (R)
When was your last massage?
MM
DD
YYYY
Please provide complete details of medical conditions and medications. You may be asked to provide a note from your physician stating that it is safe for you to receive massage.
*
Do you have any injuries or surgeries I should be aware of?
*
Have you received treatments for these injuries (i.e. chiropractic work, physical therapy, etc.)?
*
Do you experience any other conditions, treatments and/or medications you would like to share?
*
Are you or could you be pregnant?
*
What type of physical activities do you practice - work and/or leisure?
*
Height
*
Weight
*
COVID-19 RELATED QUESTIONS:
1. Have you had a fever in the last 24 hours of 100°F or above?
*
Yes
No
2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?
*
Yes
No
3. Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions?
*
Yes
No
4. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
*
Yes
No
Do you have special needs I should prepare for:
*
Do you have any questions or concerns:
*
I will honor a 24-hr notice, and be responsible for full payment of the session if I cancel after 24 hours. I understand that massage/bodywork I receive is provided for the basic purpose of relaxation and the relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of scheduled appointment. PLEASE SIGN HERE (example: /s/ Nicole Phillips).
*
Date
*
MM
DD
YYYY
Thank you!