Check In by mikeholy

VIEWS: 11 PAGES: 3

									Name: _________________________________________________________________
Address: _______________________________________________________________
City: __________________ State: _____               Zip: _________________
Home Phone: __________________________ Cell Phone: _______________________
Email Address: __________________________________________________________
Occupation: _____________________________________________________________
Date of Birth: _________________ (MM/DD/YYYY)
Age: ______________
How did you hear about us? _______________________________________________

May we contact you about periodic bodywork specials and helpful information? Y   N

Have You Ever Had A Massage Before? If yes, what type(s) and how often?
_______________________________________________________________________

When was your last massage? _______________________________________________

What is your chief complaint? Please describe current symptoms:
______________________________________________________________________________
__________________________________________________________________

Describe your current lifestyle (sleep patterns, exercise/stretching, food cravings)
______________________________________________________________________________
__________________________________________________________________
What is your current stress level on a scale of 1-10 (10 being the highest level of stress.)
________________________________________________________________________
Where in your body do you hold your stress? (Please feel free to indicate multiple areas)
________________________________________________________________________
What, if anything, triggered your current symptoms?
________________________________________________________________________
Are you currently under the care of a physician? Please explain:
________________________________________________________________________
What Medications/herbal supplements/vitamins are you taking? Please list and explain what
each is for: _________________________________________________________
______________________________________________________________________________
__________________________________________________________________

Are you receiving any other alternative care? If so, please explain:
_______________________________________________________________________

Are you pregnant?    Y N        How many weeks? _________
Do you have a history of or are you currently experiencing any of the following?
(Check all that apply)

      acid reflux                                     headaches/migraines

      allergies                                       high/low blood pressure

      anxiety                                         insomnia

      arthritis                                       irritable bowel syndrome

      asthma                                          lupus

      bursitis                                        multiple sclerosis

      bone breaks/dislocation                         osteoporosis

      cancer                                          sciatica

      carpal tunnel syndrome                          scoliosis

      chronic fatigue syndrome                        tendonitis ("Golfer's/Tennis elbow")

      depression                                      sinusitis

      diabetes                                       surgery

      digestive problems                              strains/sprains

      disk/spinal injuries                            TMJ

      epilepsy/seizure                                thyroid condition (hyper or hypo)

      fibromyalgia                                    urinary/bowel problems



Please elaborate on any current condition you checked above including length of the condition:
_______________________________________________________________________
_______________________________________________________________________
Are you experiencing any medical condition not listed above? Please explain:
________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________


By signing your name below you attest that the information provided on this form is accurate
and complete to the best of your knowledge.


Client Signature: __________________________________ Date: ___________
Client Name: ____________________________________________________________
CANCELLATION POLICY

If you need to cancel a reservation or reschedule one, we require 24 hours notice for
individual services and 48 hours for packages. Appointments cancelled or rescheduled
in less than the required time will be billed 50%. Late arrivals will result in a shortened
appointment.

Here at Zen soul our goal is to provide our clients with stellar service and we take pride
in our outstanding staff. When you reserve time with us, we always guarantee your
appointment and the full service length. For this reason we are still obligated to
compensate our staff for their time. Please understand that acupuncturists and massage
therapists only get paid when they deliver a service... therefore missed appointments
are costly and prevent us from catering to other clients. If less than 24 hours notice is
given, a service charge of 50% will be charged to you. However, if you fail to appear for
your appointment without attempting to cancel your appointment beforehand, the Full
fee is charged to your credit card.

Forms of payment:

We accept American Express, Visa, MasterCard, Discover, Spa issued Gift certificates
and cash.

Check In:

We suggest that you arrive at least 10 minutes before your appointment.

Cell Phone and Pager Etiquette:

To ensure the ultimate Zen experience, we ask that you please mute pagers and cell
phones during your visit with us.

Gratuities:

Gratuities are accepted for exceptional services. The Industry standard gratuity for a
spa service is 15% to 20% of the total cost of the treatment. However, the gratuity you
leave is entirely based on your satisfaction.

I have read the above policy and agree to abide by the written guidelines of this practice.

Signature _____________________________________________                Date _________

								
To top