Massage Therapy • Reiki • Holistic Health

Health History Form

Name:

Email:

Home Phone:

Mobile Phone:

Full Address:

Age:

Birthdate:

Date of last physical exam:

Occupation:

Please list medications:

Please list any serious illness, injuries or surgeries

Areas of pain or stiffness that need special attention?

Areas to be avoided due to acute injury or preference:

Exercise and /or sports

What is the primary position that you sleep in?

What is your previous experience with massage?

Do you use a chiropractor? yesno
If yes, who:

Is there anything else you would like to share
in order to ensure an optimal experience?

How did you hear of Body Awareness?

Policies: (please check each)

Communication
It is ok to contact me and leave a voice mail message or text on either my home or cell phone. Body Awareness may send me information in the future regarding Coaching, Personal Chef, Massage Therapy or Reiki specials, classes and workshops by E-mail or regular mail.

Payment when services are rendered
I understand that payment is required for services at the time of appointment. I also understand that Body Awareness does not accept insurance coverage for services, therefore I will be paying by cash, check, MasterCard or Visa. In the event that there is a check returned to Body Awareness / Kari Doering, there will be a service charge of $35.00 for which I am responsible.

Cancelled/Missed/ Appointment Tardiness
I understand that I need to give at least 24 hours notice when I have to cancel a previously scheduled appointment. If I do not give at least 24 hours notice of canceling my appointment, I may be charged the full price of that appointment. I will also be charged the full price for any missed (no-show) appointments. If I arrive late for a scheduled appointment, the amount of time which was missed by being late will not be refunded nor will the appointment time be extended.

Acceptance
The questions that I have answered are accurate to the best of my knowledge. I understand that choosing to work with a massage therapist should not be seen as a medical advice and is not meant to take the place of seeing licensed health professionals.

By submitting this form via email and entering my name above I am sending a digital signature of acceptance.

150 Coconut Dr Indialantic, Florida 32903
Call (203) 525-1237 to book an Appointment!

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5 months ago

Brene Brown “The Call to Courage” on Netflix tonight!
The key to connection is vulnerability....