abby jane palmer
~green room * healing arts~
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About
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CLIENT INTAKE
All information is confidential and will not be shared.
Name
*
First Name
Last Name
Email
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birthday
MM
DD
YYYY
Phone
(###)
###
####
Pronouns
She/Her
He/Him
They/Them
Have you had a professional massage before?
*
Yes
No
If Yes, What kind of pressure do you prefer from 1. light touch to 10. deep tissue?
*
Please tell me about any and all injuries or surgeries and the date they occured.
*
Is there anything you are be treated for your doctor would want me to know about?
*
Any medication that I should know about ?
*
What is going on in your body? Where are you holding tension? Areas of pain?
*
Have you been experiencing any emotional or trauma stressors I should be aware of?
What do you do for work? How do you use your body?
What kind of exercise/movement/body work do you do regularly?
Do you like essential oils?
No
Yes, I like them all
No Lavender
No Peppermint
No Citrus
No Eucalyptus
Do you have any allergies to lotions or oils?
*
Yes
No
If yes, what?
Do you have a preference in music?
Hot & Cold
I run hot
I run cold
Niether
Open to heat packs on sore areas
Table warmer on always
Table warmer on when it's cold
Open to Cold stones on areas that are inflammed
Do you want CBD?
*
Yes
No
What are your intentions and goals for our time together? This can be something more than physical.
Would you like your abdomen massaged? Can be helpful for digestive, urinary and menstrual issues. If yes, please list any of the issues you have been experiencing.
Would you like cupping?
Yes
No
Maybe
Do you want me to wear a mask?
Yes
No
Please write your name to acknowledge that you understand: The massage and body work that I receive is provided is for the purpose of relaxation stress reduction and relief of muscular tension. If you experience pain or any discomfort during the session, you will inform Abby immediately. You agree that you have disclosed any and all health information that would be relevant to receiving massage and have disclosed anything that would make receiving massage contraindicated. It is your right to stop the session at any time. You understand that illicit or sexually suggestive remarks or advances will result in the termination of the session. Our time together is valuable and you agree to give 24 hours notice, unless there is a true emergency. If you miss or fail to cancel within the 24 hour window before, You agree to pay the full appointment fee and understand in the future may need to prepay to secure your appointment.
*
Thank you!