Bodywork Intake Form

Brief health intake questions, and client agreement, for clients scheduling bodywork. (Zero Balancing, Craniosacral, Reiki)

Name, age, and best phone number(s) (And let me know if you generally prefer phone, text or email.)

Address

Have you had any joint replacements? Please describe, including when it/they were replaced.

Have you had any surgeries or illnesses in the past 6 months? Please explain.

Do you have any current health issues I should know about? Please describe.

Please "sign" by typing your name and today's date, confirming the following:

"I understand that bodywork is not a replacement for medical care. As a Licensed Massage Therapist, Megan Ayrault does not diagnose or treat illness or injury. “Bodywork” includes a variety of complementary modalities, all within a licensed massage therapist's (LMT's) scope of practice, which support the health and well-being of the client, reduce stress, and improve musculoskeletal and energy balance.

I understand that Megan Ayrault does not bill insurance, and payment is due at time of appointment, or in advance with a package. 

I also agree to do my best to call with AT LEAST 48 hrs NOTICE IF I NEED TO RESCHEDULE OR CANCEL an appointment. I do not expect a reminder call prior to my appointments unless I request one."