New Client Form - Entropy Treatment Rooms

Please fill out this online form as thoroughly as possible before your first appointment. Doing this before you arrive means less time doing paperwork and more time treating you.

Health Form

Personal Information

Name *

First

Last

Email *

Date of Birth *//

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Occupation

Sex

Male
Female

Emergency Contact

Name *

First

Last

Phone

Relationship

Health History

Please provide further details, if necessary.

Do you have any allergies? (Particularly to oils, creams and lotions)

Are you sensitive to any fragrances or perfumes?

Do you have sensitive skin?

Are you taking any medications?

Have you ever had any serious or chronic illnesses, operations or traumatic accidents?

Lifestyle History

Work Activity

Sitting
Standing
Light Labour
Heavy Labour

Exercise Activity

None
Gentle
Moderate
Heavy

Have you had a professional massage treatment before?

Pregnancy Massage

Are you pregnant?

Client Condition

Are you currently experiencing pain or discomfort?

If yes, please give short description

Treatment Preferences

Do you have any particular goals for treatment?

If yes, please give more details in the last section.

Prioritise which areas of your body you would most like to be massaged:

Is there any areas of your body that you would prefer NOT to be massaged? (Common areas may include the feet or the abdomen)

Is there anything else you would like me to know before your treatment?

Disclaimer: If I experience any pain or discomfort during this 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 should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage 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 Entropy Rooms updated as to any changes in my medical profile and understand that there shall be no liability on Entropy Rooms' 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 the scheduled appointment. Understanding all of this, I give my consent to receive care. *

I agree