Client Intake Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Birth Date

We Like to Send Presents ;)

MM

DD

YYYY

Referred By

We'd love to say Thank You!

First Name

Last Name

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Date of Massage Requested *

MM

DD

YYYY

Time of Massage Requested *

Hour

Minute

Second

AM PM

Address of Where Massage Will Be Performed? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I am over 21 years old *

Yes

No

I understand that the massage given to me by Traveling Hands Company is for the purpose of stress reduction, pain reduction, relief from muscle tension, and increasing circulation. *

Yes

No

I understand that these massage services utilize cannabis oil. Although I will not feel “stoned” or experience any intoxicating effects, I acknowledge that I will refrain from operating a motor vehicle for two hours after my session ends. *

Yes

No

I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy. *

Yes

No

I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have. I have stated all my known medical conditions, recent surgeries, allergies, and medications, and I will keep the massage therapist updated on any changes. *

Yes

No

I understand that this is a professional service. I acknowledge that ANY sexual comments or advances will result in immediate termination of the massage. I will also be fully liable for the cost of the session. *

Yes

No

Everyone that works with Traveling Hands Company is a highly trained professional with many years of experience. As a result, their time is valuable. I understand that I will be charged a late cancellation fee of $50 for any cancellations with less than 24 hours notice. If the therapist has been dispatched to my location and I am not there, or cancel while the therapist is on the way, I will be billed and will be liable for the full amount of my service. *

Yes

No

Have you had a fever in the last 24 hours of 100°F or above? *

Yes

No

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? *

Yes

No

Do you now, or have you recently had, any chills, muscle aches, new loss of taste or smell, or new rashes or lesions? *

Yes

No

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-like symptoms? *

Yes

No