St8newalker Stone Massage

PRINTABLE CLIENT INFORMATION FORM    © Copyright Lakota Stone Nation, 2000-2011All Rights Reserved  www.ST8NEWALKER.com

605-722-0004

Please PRINT, FILL OUT, SIGN and BRING this form with you for your first session

My first appointment is scheduled for

Date of:__________________________Day:__________________Time:_____________
If you cannot make this scheduled appointment date as agreed, Please call at least 12 hours in advance of appointment to cancel.

CLICK HERE TO RETURN TO WEBSITE

 Name______________________________________________________________________________________

 Address________________________________________City__________________State______Zip_________

 Home Phone_____________________Email:________________________Cell phone:___________________

If you have a specific medical condition or symptoms, bodywork may be contraindicated or a referral from your primary care provider may be required prior to service being provided.  Please be advised that the following necessary information will be kept in strict confidence, and on file only for insurance purposes /or to inform practitioner so that appropriate therapies may be administered and/or contraindicated.  Please list brief explanation of your physical complaints – health concerns:

Yes    No    Are you pregnant?  ______________Months?____________
Yes    No    Arthritis? 
Yes    No    Allergies?  Explain
Yes    No    Any rashes or skin problems?  List:
Yes    No    Do you have any contagious diseases? List:
Yes    No    Any childhood trauma or emotional issues requiring treatment?
(use back of sheet for comments)
Yes    No    Do you have High blood pressure?
Yes    No    Do you suffer from epilepsy or seizures?
Yes    No    Any cardiac or circulatory problems? List:
Yes    No    Do you have any other health issues or concerns? 
(use back of sheet for comments)

I understand that I am responsible for my own health and I have chosen to receive this therapy for my own education and health reasons, and that all services I receive are provided for the basic purpose of relaxation and relief of stress factors.  If I experience any pain or discomfort during a session, I will immediately inform the practitioner so that the discomfort may be addressed.  I further understand that bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment, and that practitioner is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing on website or said in the course of the session should be construed as such.

I affirm that I have stated all my known health conditions, and answered all questions honestly.  I agree to keep practitioner updated as to any changes in my health profile and I understand that there shall be no liability on the practitioner’s part should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. 

Client Signature (or signature of legal parent or guardian if minor):  

_____________________________________________________________Date:_______________