Rolf Method Body Work.com

Please take a moment to fill out this pre-session intake form. Complete as much of the form as possible and submit. This will speed the intake process when you arrive for your appointment. Thank you.

First Name: Last Name:

Height:

Weight:

D.O.B:

Address:

City:

State:

Zip:

Telephone: ( )

Work: ( )

Email Address :

Method of Payment: CASH CHECK VISA MASTERCARD

Reason for visit:

Referred By:

Have you ever had professional body work done before? NO YES

Do you have a primary complaint?

How did this condition develop?

What makes it worse?

What makes it better?

Whithin the past year, have you been under the routine care of a health provider(s), i.e. chiropractor, physician, psychotherapist, alternative practitioner, etc? NO YES

If yes please list name of provider and condition:

Health History

Please check any condition that applies to you.

What medical conditions pertain to you that do not appear on the list:

Are you currently taking any over the counter medications? NO YES
- if yes please list the name of the medication and reason for using:

On a daily basis, what is the average consumption of:

Describe any significant bodily injuries that you can remember (even in childhood) and when they happened, i.e. accidents, sprains, falls, bone fractures, physical abuse, etc.:

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.

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.

Signing below indicated that you have read these policies.

(In lieu of a signature, we request that you select the month that you were born in,
your initials, and the date - stating that you agree with the statements, information and policies above.)

Month: Initials: Date:

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