Kauai Massages Therapy
The Massage Hut Coconut Market Place Kauai,HI Client Intake Form

Please note: Any information exchanged on this form or during a massage therapy session is considered confidential and used only to provide you with the best health care services possible.


Name __________________________________________

Address ________________________________________

City ___________________________________________

State _______ Zip _____________

Massage Time Preference?

Time _____________ Date _____________

Day _____________

Place? Be Specific with Directions Locations So We Can Better Assist you - Write Your Hotel,Vacation Rental/Home On Kauai - Here -______________________________________________


Birth Date _________________________

Telephone # _______________________

E-mail address: __________________________________
Would you like to receive occasional newsletters or specials via e-mail?______Credit Card # Visa Master Discovery Most Magor Credit cards's Accepted

visa.jpgCard Holder _____________

Credit Card # _______________________

CVC# On Back _____________

____ High Blood Pressure
____ Contact Lens
____ Low Back Pain
____ Allergy to Nut Oils
____ Osteoporosis
____ Diabetes
____ Pregnant		 ____ Blood Clots
____ Low Blood Pressure
____ Varicose Veins
____ Bursitis
____ Skin Infections
____ Numbness / Tingling
____ Burning / Itching
   ____ Hypo or Hyperglycemia
____ Contagious Conditions
____ Muscle Sprain / Strain
____ Heart Attack / Stroke
____ Paralysis of any kind
____ Arthritis
____ Headaches

Have you had any serious or chronic illness, operations, or traumatic accidents? _____________________

If yes, please explain: _____________________________________________________________________

Are you currently, or have you at any time within the last 12 months been under the care of a physician?

If so, for what condition?_____________________________________________________________

I have completed this health form to the best of my knowledge and consent to receive massage therapy. I understand that massage therapy is a therapeutic health aid and is non-sexual. I UNDERSTAND THAT MASSAGE THERAPISTS DO NOT DIAGNOSE ILLNESS, DISEASE OR ANY PHYSICAL OR MENTAL DISORDER; NOR DO THEY PRESCRIBE MEDICAL TREATMENT, PHARMACEUTICALS, OR PERFORM SPINAL THRUST MANIPULATIONS. I ACKNOWLEDGE THAT MASSAGE IS NOT A SUBSTITUTE FOR MEDICAL EXAMINATIONS OR DIAGNOSIS, AND THAT IT IS RECOMMENDED THAT I SEE A PRIMARY HEALTH CARE PROVIDER FOR THAT SERVICE.

If I am not able to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In case of an emergency, I will call ASAP to reschedule my appointment.

If I miss a scheduled appointment without giving 24 hours' notice, I agree to pay any missed appointment charge applicable.
Name (signature) _________________________________________ Date _______________________
To make an appointment, call 808-635-2324.E-Mail sales@kauaimassages.com
© 2008 Kauai Massages Out Call Bodywork Intake Form