New Client Questionnaire

Salutation?

First Name:


Middle Initial


Last Name


Street Address


City


State


Zip Code


Cell Phone Number


Email Address


Date of Birth


How did you first hear about us?


    If Pregnant:
What is Your Due Date?



Who is Your Doctor (Ob/Gyn)?  Also Specify Midwife if you have one.


Have you had or are you having any complications during your pregnancy that may prevent you from having a massage?

If "Yes" please explain.


Signature: Please Type Your Full Name [your typed name is your signature]
Your Full Name:



Cancellation/No-Show Policy
This policy allows us to offer the best service to each and every client.  We have a 48-hour cancellation notice required for all services.  One exception to this: If you are getting multiple treatments and the total treatment time lasts more than 1 hour and 45 minutes, we have a 72-hour cancellation policy.  The full treatment fee will be charged for cancellations received with less notice.  However, if we are able to fill the appointment you will not be charged.  If you do not show up for any scheduled appointment you will be charged the entire amount of the scheduled treatment.

Please enter the code exactly as you see above: