Intake About youAll information submitted through this form is confidential and for professional use only. Your information will not be sold or shared. Please complete this form so we may legally treat you. Thank you, The Bodeze Urban Spa team.Name* First Last Address* Street Address Address Line 2 City AlbertaAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Email* Date of Birth* Gender*FemaleMalePhone - Primary*Phone - SecondaryHelp us serve you betterOccupation*Hobbies*Emergency Contact Full Name* First Last Emergency Contact Phone*Why are you seeking a massage therapist/what is your current concern?*Are you visiting as the result of a motor vehicle accident?*YesNoPlease describe resulting injuries?*Are you currently seeing a helathcare professional?*YesNoIf yes, please list names and reasons/treatments?*Are you currently taking any medication?*YesNoIf yes, please list name and reason for medication(s).*Do you have any allergies we should know about?*YesNoIf yes, please list your allergies?*Are you currently pregnant or trying to get pregnant?* Yes No Please review the list and check those conditions that have affected your health either recently or in the past.* Arthritis Broken/dislocated Bones Chronic Pain Hepatitis (A,B,C, other) Heart Conditions Surgery Depression, panic disorder, other psych condition Headaches Scoliosis Diabetes Bruise Easily Constipation/Diarrhea Seizures Stroke Skin Conditions Muscle Strain/Sprain Blood Clots Cancer Auto-immune condition TMJ Disorder High Blood Pressure Insomnia Back Problems Whiplash None Final StepBy signing below you agree to the following.I have stated all medical conditions that I am aware of and will keep my practitioner informed of any changes. I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so the pressure can be adjusted. I understand that massage/bodywork should not be considered as a substitute for medical examinations, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical aliment of which I am aware. I further understand the benefits and risks of massage and give my consent for massage. I assume all risks and responsibilities for myself and release Bod-eze Urban Spa and the therapist from responsibility from any injury or liability that may occur during treatment. I agree to provide 24-hour cancellation notice. If I fail to do so, I agree to pay the $40.00 appointment fee. Consent* First Last Date* Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.