Intake Form

Please take a moment to fill out this pre-session intake form. This will help speed up the intake process when you arrive for your appointment.

Personal Info:

 
 
 

Health Info:

Health History:


















Are you currently taking any over the counter medications?
On a daily basis, what is the average consumption of:









 

Because a massage therapist must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations, and I will inform my massage therapist of any changes in my physical health. I understand and agree that ;(1) the massage therapy that I am given is for the purpose of stress reduction, relief from muscular tension or spasm, and for improving circulation; (2) that a massage therapist neither diagnoses illness, disease, or any other medical, physical or mental disorder, nor performs any spinal manipulations; (3) I am responsible for consulting a qualified physician for any physical ailments requiring diagnoses.

I agree that all the services rendered to me are charged directly to me and I am responsible for payment unless prior arrangements have been made. I agree to pay for all scheduled appointments that I am unable to keep unless I notify my therapist at least 48 hours in advance.

Acceptable Payment Methods
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Cancellation Policy
No charge will be incurred for cancellation notification given at least 48 hours from the time of the scheduled session. Likewise, no charge will be incurred for cancellation given in less than 24 hours lead time when the appointment is subsequently re-booked with another client. If the appointment time is not resheduled with another client for the same time you were originally scheduled you will be responsible for payment in full.

All parties are responsible for handling career and other life demands that compete with the time of the scheduled session appointment.

By submitting this form, you indicate that you have read these policies.

Practitioner

Frank Epstein, Certified Rolfer,

Frank Epstein BA, LMT, CNMT, NCTMB

My job is to facilitate physical change that alleviates pain while allowing your body freer movements and better alignment.