Holistic Medical Massage Therapy

Serenity in the grove

Serenity in the Grove

176 Randolph Rd.

Oak Ridge TN  37830



Client Information

Name:___________________________________  Date of Birth: _______



                  Street                                     City            State           Zip


 (cell phone #) __________________ ( home or office)____________


E-mail address:_________________________________________________


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.



________________________________      __________________________

Signature                                                  Date

Medical History


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:?________