Services
About Nicole
Connect & Book
Services
About Nicole
Connect & Book
Nicole Phillips, Certified Massage Therapist
Name
*
First Name
Last Name
Pronouns
Email
*
Phone
*
(###)
###
####
Date of birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Person
*
Phone (Emergency Contact)
*
(###)
###
####
Referred by
What is your reason for seeking massage?
*
Are you or could you be pregnant? How many weeks?
*
How many births have you had? Any C-sections?
*
Are you experiencing pain, soreness, or tension in any of the following areas?
*
Check all that apply.
Head
Jaw
Neck
Shoulder (L)
Shoulder (R)
Arm (L)
Arm (R)
Wrist (L)
Wrist (R)
Upper Back
Mid-Back
Low Back
Chest
Abdomen
Calves (L)
Calves (R)
Thigh (L)
Thigh (R)
Knee (L)
Knee (R)
Ankle (L)
Ankle (R)
Hip (L)
Hip (R)
Height
*
Weight
*
When was your last massage?
MM
DD
YYYY
Please provide complete details of medical conditions and medications. You may be asked to provide a note from your physician stating that it is safe for you to receive massage.
*
Do you have any injuries or surgeries I should be aware of?
*
Have you received treatments for these injuries (i.e. chiropractic work, physical therapy, etc.)?
*
What type of physical activities do you practice - work and/or leisure?
*
Do you have special needs I should prepare for:
*
Do you have any questions or concerns:
*
I will honor a 24-hr notice, and be responsible for full payment of the session if I cancel after 24 hours. I understand that massage/bodywork I receive is provided for the basic purpose of relaxation and the relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical illness, and that nothing said in the course of the session given should be construed as such. Because massage/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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of scheduled appointment. PLEASE SIGN HERE (example: /s/ Nicole Phillips).
*
Date
*
MM
DD
YYYY
Thank you!
