Name *

First Name

Last Name

Date of Birth: *

MM

DD

YYYY

Phone: *

Country

(###)

###

####

Home Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Address- Where you want the massage to take place (mobile / chair event): *

E.g. if you are visiting from out of town this would not be your home address. *If you are coming for an in-studio session please just put the office address: 2186 South Holly, Suite 206 Denver, Colorado 80222

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please Select Your Pronouns: *

she / her

he / him

they / them

Emergency Contact Phone Number: *

Country

(###)

###

####

Date of Initial Visit: *

MM

DD

YYYY

Have you had a professional massage before? *

Yes

No

Are you currently pregnant? *

Yes

No

*Please Review: *

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

I have read through and understand all of the policies The Mindful Bodyworker has implemented. I agree to all of them and the cancellation policy. I release the licensed massage therapist and The Mindful Bodyworker of any responsibility from receiving massage therapy.

Today's Date: *

MM

DD

YYYY