Heron's Rest Massage and Bodywork
Joyce Calvitti, LMT Perkiomenville, PA 215-896-2451

New Client Forms

If you wish to fill in the following forms before your first session, please copy and paste all information below into a printable program.

 

CONFIDENTIAL CLIENT INFORMATION   (please print clearly)

 

NAME _________________________________DATE _______________

 

FULL ADDRESS_____________________________________________

 

PHONE (home)______________________(work)___________________

 

               (cell)_______________________(email)___________________

 

BIRTH DATE_________________________ AGE___________________

 

EMERGENCY CONTACT AND #_________________________________

 

REFERRED BY______________________________________________

 

OCCUPATION_______________________________________________

 

REGULAR ACTIVITIES/EXERCISE/PASTIMES______________________

 

SLEEPING POSITION - SIDE/BACK/STOMACH/ARM POSITION

LEFT or RIGHT HANDED                              

                                           (please circle one)

First Massage~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Y/N

Areas of Acute/Chronic Pain/Discomfort/Tension.............…….….Y/N

Recent or Old Injuries/Surgeries/Scars~~~~~~~~~~~~~~~~~~~~Y/N

Nerve Damage(numb/tingling).….…….…………….....….….…....Y/N

Heart/Vein/Circulation Concerns ~~~~~~~~~~~~~~~~~~~~~~~~Y/N

Visited Doctor in Last 6 Months….…...………….……..……..…..Y/N

Dermatologist for check-ups ~~~~~~~~~~~~~~~~~~~~~~~~~~~Y/N

Contagious Conditions.…...........................................................…..Y/N

Pregnant~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Y/N

Medications……………………………...…………………......….Y/N

Allergies ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Y/N

Wear Contacts..…………………………...….……………….........Y/N

Loose Dental Work ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Y/N

Any Questions/Concerns.………………………………….…...…..Y/N

 

I UNDERSTAND THE IMPORTANCE OF RELATING ANY EXISTING CONDITION BEFORE RECEIVING  A MASSAGE.

I UNDERSTAND IT WILL BE  MY RESPONSIBILITY TO INFORM THE THERAPIST OF ANY CHANGES TO THE INFORMATION PROVIDED ON THIS FORM.

I UNDERSTAND THAT THE MASSAGE THERAPIST DOES NOT DIAGNOSE MEDICAL OR MENTAL CONDITIONS, PRESCRIBE MEDICATIONS OR PERFORM ANY SERVICE OUTSIDE OF THE PROFESSIONAL TRAINING RECEIVED.

I UNDERSTAND THAT THE MASSAGE THERAPY GIVEN HERE IS FOR THE PURPOSE OF STRESS REDUCTION, MUSCLE CONDITIONING, INCREASED CIRCULATION, ENERGY FLOW AND GENERAL GOOD HEALTH

 

Signature  _________________________________Date ________________

The Pennsylvania Massage Therapy Board requests that Massage Therapists make practice policies available to new clients. I have included information which hopefully helps with some questions or concerns you may have. Please indicate, by signing below, that you have read all the information included. Thank you, Joyce Calvitti, LMT

For all information, questions and scheduling please call or text: 215-896-2451. Feel free to leave a detailed message. Calls or texts will be returned as soon as possible. If you prefer, you may email me at: heronsrest1@gmail.com.

Payment is by cash or check only, and is due at time of service. Receipt upon request. There is no credit card availability at this time. Apologies for any inconveniences this may create.

Gift Certificates are available. Certificates never expire for purchased amount. Expiration date, noted on certificate, guarantees service listed. After expiration date, an extra cost will be added if price of service has increased. Some services may no longer be available. At any time, certificate is transferable back to purchaser.

Times for Sessions are approximate. Occasionally sessions run over the indicated minutes. Please let me know if you have a time constraint. I will be sure to comply with your schedule. See Website for listed times at: http://www.joycecalvitti.massagetherapy.com.

Cancellation Policy:
It is understandable that unexpected events occasionally happen in our lives. If you do need to canceling an appointment, please give at least a 24 hour notice, or as soon as you can. This allows the opportunity for someone else to schedule during that time. If for any reason I need to cancel, I will do my best to give as much notice as absolutely possible.

For fair notice to all clients, please take a moment to carefully note the following policies:
Late Arrivals
If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, it will be determined if there is enough time remaining to start a treatment. With respect and consideration, please plan accordingly.

No-Shows
If you either forget or consciously choose to forgo an appointment and, as a courtesy, do not respond to my phone or text inquiry in a timely fashion, you will be considered a “no-show.” There will be a charge of $20 for the missed appointment. To avoid this situation, please refer to and update your calendar when appointments are made. Payment must be paid at next appointment or sent to: 2116 Rahn Ave, Perkiomenville PA 18074

Thank you, so very much. Awareness of these policies is helpful for a clear and professional relationship.

Print Name _______________________Signature  ___________________________Date  ________

 

 

Associated Bodywork & Massage Professionals
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