EmailMe Form - RIT Chair Massage Intake Form

RIT Chair Massage Intake Form
Please fill this out and submit prior to your appointment.
Your health information will be kept completely confidential. We will not use or share your contact information for marketing purposes. New York State requires Licensed Massage Therapists to collect the name, address and health history of their clients.

Upon submission of this form you will receive a copy of it in your email from "noreply@emailmeform.com"

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Today's Date *

YYYY

Name *

Prefix

First *

Last *

Suffix

Address *

Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

Phone Number (Work) *

###

####

Phone Number (Mobile)

###

####

Work Email *

Health History
Your health information helps the therapist work with you safely and effectively.

Check all that apply:

knee problems make it difficult to kneel

pregnant

cold/flu/infectious disease

seizures

bruise easily

skin condition/rash/open cut

high or low blood pressure

recently had blood clots

cancer

lymph nodes removed

neuropathy

received radiation or chemo- therapy

surgery in the last 8 weeks

neck/spine problems

implanted medical devises

breast augmentation

fragile bones/osteoporosis

taking pain medications

chronic pain condition

arthritis

heart condition

Any other information regarding your health you would like to share?

CHAIR SAFETY

Please check the YES box if you weigh more than 300 lbs, the maximum weight allowance for our massage chair. If so alternative arrangements can be made for your safety. *

YES

AGREEMENT

Agreement. Please check here if you have read and agree to the following: I understand this massage is for relaxation and not for medical care. I am responsible for indicating to the therapist if I am uncomfortable or need to stop the massage at any time. *

I Agree

Voluntary Survey
At this time we have a male therapist at this time. For future reference we'd like to know if you have a gender preference for your massage therapist.

Female

Male

No preference

Submitting this form
If you do not get a confirmation screen immediately upon clicking the "submit" button please review the form to make sure you didn't skip a required field.

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