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Client Name
Preferred phone number
Email
Best time to call:
Preferred form of communication:
Types of massage/bodywork received
Preferred types of massage
Reasons for seeking massage? (relaxation, injury, etc.)
Description of injury/health condition:
Possible complications/medications:
Are you seeking insurance reimbursement?
Yes
No
Any /personal injury?
Yes
No
Communication Checklist
Fees/forms of payment
Cancellation/No-show policy
Late arrival policy
Confidentiality
Parking/directions
Work setting
Clothing/shiatsu
Modesty/Nonsexual/draping
Food/drugs/alcohol
Oils/lotions/allergies
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Screening Questionnaire form
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