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Client Intake Form

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Name *

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Emergency Contact___________Phone_____________Relation_______________ *

How did you hear about this us? *

Friend Chiropractor Doctor MD, DO, or DC Physical or Occupational therapist Google Yelp Facebook Advertisement Drive-by Other

Please specify above choice: Friend`s or doctor`s name, advertisement name, etc. *

Typically what pressure do you prefer? *

Light / medium Medium / heavy

Are you pregnant? *

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If yes, how many weeks?_____ Due date? ____ *

Please select all current conditions you are experiencing *

Spinal disorders Osteoporosis Bone fractures Arthritis Fibromyalgia Accidents Injuries Swelling Pain Numbness / tingling Muscle tension Allergies Sinus problems Headaches Chronic stress Heart conditions High / low blood pressure Stroke Varicose veins Blood clots Diabetes Cancer Lung conditions Digestive problems Nervous disorders Depression Surgery Jaw clenching / grinding Pregnancy Inactivity

Please select all conditions you have experienced in the last two years *

Other conditions or information *

Are you currently under the care of an MD, DO, or DC? If so, for what condition? *

Have you taken any medication today? If so, what and for what condition? *

Reason for massage session today *

Please do not perform massage on *

NFORMED CONSENT: The information I have provided to assess risks and a treatment plan, are true to the best of my knowledge. I agree to inform my massage therapist of any health changes. I understand that massage therapy is provided for treatment of soft tissues, circulation improvement and for relaxation, and that massage therapists do not diagnose or do spinal manipulations. It is my right to refuse ant treatment before or during the massage therapy session.I will be draped for the comfort of warmth and modesty according to the clinic`s policies. I will tell my therapist if I am uncomfortable in any way. I understand that any sexual comments, jokes, or advances will be reason to terminate the session with full payment due. Ka lani massage is not responsible for any items lost or misplaced. * *

I have read and understand

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Parent / guardian signature (under age 18) (leave blank - to be signed upon arrival) *

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Therapist signature (to be signed before session) *

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24 Hour Cancellation/ Late arrival Policies ---------- We understand that unanticipated events happen occasionally in everyone’s life. When you book an appointment, that time is set aside for you, and missed appointments prevent us from accommodating other clients. In our desire to be effective and fair to all of our clients and out of consideration for therapists time, we have adopted the following policies: 24 hour advance notice is required when canceling or rescheduling an appointment. This allows the opportunity for someone else to schedule an appointment. If an emergency situation arises, please let us know so that we can treat your specific situation with personal attention. We recognize that there are circumstances that are out of your control (sudden illness, family emergencies, etc.) and make an exception to the policies on those rare occasions. If you are unable to give your therapist a reasonable time of advance notice: First offense: In the event of a late cancellations, although we will do our very best to get this time re-booked and not charge you, if at the end of day this time slot remains un-booked, the credit card on file will be charged the cancellation fee of $30.00. Second offense & beyond: In the event of subsequent late cancellations, although we will do our very best to get this time re-booked and not charge you, if at the end of day this time slot remains un-booked, the credit card on file will be charged the full amount. No-shows: Anyone who either forgets or consciously chooses to forgo their appointment with no contact, will be considered a “no-show” and will be charged the full amount for their “missed” appointment. Arriving late: Appointment times have been arranged specifically for you. If you arrive late your session may be shortened in order to accommodate others whose appointments follow yours. Regardless of the length of the treatment actually given, you will be responsible for the “full” session, however we will do our best to satisfy the scheduled time. *

I agree to the terms of Ka lani`s cancellation/no show policy

We offer a Monthly Maintenance Program, as well as a variety of packages for discounted rates. Please ask the front desk for details. *

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Come visit us soon!

603-380-7174
200 Griffin Road
Suite 6
Portsmouth, NH 03801

Hours

Monday - Saturday 8:45 am - 9:15 pm
Sunday Closed

**** We are running only one shift on Saturday's ....
(alternating morning and evening shifts)

Voted Best Massage Practice
7x Finalist
5x Winner

Sessions include time for client consultation and dressing.

Client Intake Form​

Come visit us soon!

Hours

Client Intake Form