New Client Intake Form - StressBusters

New Client Form

New Client Intake Form

Salutation?

First Name

Middle Initial

Last Name

Street Address

City

St

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?

Yes

No

If "Yes" please explain.

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

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.

If you are human, leave this field blank.