Balanced Newtrition

Pain relief never felt so good! A new way to nourish the mind, body, and soul!

Keith Massage Client In-Take Form

In the state of Texas, we required to keep a client intake form on all current massage clients.  The state requires us to gather specific information for your safety and ours.


To help cut down on the amount of paper we consume, we are asking everyone to take a moment to fill out the following form. This form MUST be filled out entirely. 


The state also requires us to update our client intake forms every two years. So, whether you're an existing client or new to our office, we will need you to take a moment to fill out this form unless you've been notified otherwise.


Your information is completely confidential, nor is your information ever sold to a third party.


As always, we continue to provide the very best quality in service and client care as we continue to do what we love; Helping Others Feel Good!


For those of you that do no wish to fill this form out online, we will be providing you a paper copy on your next visit, which will need to be filled out before your session.


Thank you for your help and understanding!


NOTE: Anything with a * must be filled in or the form will not submit. This means you will receive an error message that the form did not go through. Please be sure to fill out all * as instructed to ensure a good send.​

Please be sure to include: Street Address, City, State, Zip
Gender*
Please be sure to list name and phone number.
Have you experienced massage or bodywork in the past?*
We only do therapeutic massage, do you understand what this means?*
Please type your name below if you understand that draping is required at this establishment and that clients shall remained draped at all times. Clients that expose themselves to therapists, make sexual advancements, and/or use rude behavior or language in anyway will be asked to leave immediately and will be documented.
Have you been referred by a physician to have bodywork or skilled touch?*
If you have been referred by a physician, please provide his/her name and the goal or reason for the referral.
Do you bruise easily?*
Are you pregnant?*
What kind of pressure do you like?*
Please list any known allergies below. If you do not have any known allergies, please put NA.
Please only list RECENT surgeries. If none, please put NA.
You may abbreviate when possible. If you are not taking any drugs or herbs, please type in NA.
An example would be that you are temporarily on blood thinners for blood clots, this is something we need to know. If nothing, please put NA.
Please fill in below what your goals are. If there are no goals, simply type in NA.
Please type your name below to serve as your electronic signature
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Thank you! Your Intake form has been successfully completed.

© 2016 Balanced Newtrition

1101 Ridge Road, Suite 134

Rockwall, Texas 75087

469-562-2381

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