You must install Adobe Flash to view this content.
A Sanctuary for Healing
Laura Magpali

Patient Intake Form


Two Options:

Download PDF
and bring it in
Or fill in the form to the right


 PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED.

I understand that the bodywork I receive is provided for the purpose of deep relaxation and promotion of whole body health.  I further understand that bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment.  I understand that bodywork therapists are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe, or treat any physical or mental illnesses, and that nothing said in the course of the session given should be construed as such.  Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly.  I agree to keep the therapist updated to any changes to my medical profile, and understand that there shall be no liability on the therapist’s part should I neglect to do so.  It is also understood that any illicit or sexually suggestive remarks or advances made by either of us will result in immediate termination of the session. I understand that 24-hour notice is required for cancellation of appointments and I will be charged for missed appointments.


Name *
Address: *
Home Phone: *
Work Phone:
Cell:
City: *
State: *
Zip: *
Date of Birth: *
Email: *
Physician / healthcare provider
Occupation/Typical body positions:
Date of Accident
Referred by:
Cash or insurance? *
Insurance provider:
Emergency Contact (name & phone number) *
Have you ever had professional massage? *
 Yes
 No
Do you experience frequent headaches? *
 Yes
 No
Do you suffer frequently from stress? Depression? *
 Yes
 No
Do you have tension or soreness in a specific area? *
 Yes
 No
Do you have numbness or stabbing pains anywhere *
 Yes
 No
Have you had any broken bones, accidents, and/or falls? *
 Yes
 No
Are you very sensitive to touch / pressure in any area? *
 Yes
 No
Have you had jaw surgery, and/or are you wearing dentures? *
 Yes
 No
Do you have any implants? *
 Yes
 No
Are you diabetic? *
 Yes
 No
Do you have high or low blood pressure? *
 Yes
 No
Do you have cardiac, circulatory, or kidney issues? *
 Yes
 No
you affected by seizure disorders or epilepsy? *
 Yes
 No
Are you taking medication or supplements for any of these or any other condition? *
 Yes
 No
Are you pregnant? *
 Yes
 No
you ever had surgery? If yes, please explain in the comments area. *
 Yes
 No
Are you allergic to anything? *
 Yes
 No
What?
Do you have any other medical or health conditions? *
 Yes
 No
Comments
Digital Client Signature: *
Date *