Holistic Medical Massage Therapy
Serenity in the grove
Serenity in the Grove
176 Randolph Rd.
Oak Ridge TN 37830
Name:___________________________________ Date of Birth: _______
Street City State Zip
(cell phone #) __________________ ( home or office)____________
Employer Name and Address: _____________________________________
Have you had bodywork/massage before?
What led you to schedule this massage? _____________________________
How did you hear about Serenity in the Grove or Amanda? _____________
Was this a gift Certificate?_________
Is there anything you want the therapist to know about your comfort requirements? (music, aromatherapy, lighting, use of table warmer etc.)
Agreement: I understand that massage and bodywork are for the promotion of health, well being, stress reduction and/or relief from myofascial discomfort. Massage therapists do not diagnose physical or emotional disorder. Massage is not an alternative for medical or emotional healthcare. Therefore, I will continue to see health care provider(s) regarding any health issues. I will keep the massage therapist informed of any changes in my health.
I understand that if the massage therapist starts a session late, she will make it up to me at the end of my session if possible, or will reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is not penalized. I agree to give 24 hour notice for a scheduled session that I can not keep. I am aware that I may be charged the full fee for any missed sessions or for sessions that I do not give 24 hour notice to cancel or reschedule.
Do you or have you had any of the following? If so, describe and give dates.
Significant medical conditions (circle): Cancer Diabetes Seizures
High Blood Pressure Heart Disease Hepatitis Other:___________
Do you have trouble with bruising, varicose veins, or blood clots? ____
Do you have any signs of infection or inflammation? __________________
Surgeries (describe and give dates):_________________________________
Physical or emotional trauma (e.g., accidents, crises, abuse, death):_____
Are you pregnant or trying to become pregnant?____# of children?_______ Are you currently under a doctor’s care for these or any medical conditions not listed above? Describe: _____________________________________
In the past 4 hours have you taken any over the counter or prescription medications?_____
Do you have any other conditions or concerns the massage therapist should know about? __________________________________________
Allergies to drugs, chemicals, foods, oils etc:?________