New Client Intake Form

New Client Intake Form

Save time at your appointment by printing and filling out your new client intake form beforehand! We look forward to meeting you and helping you take relaxation to a new level.

Take a look at our spa and massage services and staff to learn more about our locally owned and operated business.
New Client Intake Form

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When you make an appointment with Revive Professional Massage Therapy Clinic, the benefits are clear:
  • The best massage services
  • Highly trained staff
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Schedule your first appointment.

Call 701-893-3888 today.

Revive Professional Massage Therapy Clinic Confidential Client Intake form

General and medical information

Yes
No
Yes
No
Yes
No
Yes
No

On a scale from 1-10, 10=highest, rate your levels of:

1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
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6
7
8
9
10
Better
Worse

Please check all that apply

Skin problems
Hives‎‎
Swollen gland‎‎
Joint problems‎
Sacroiliac problems‎
Sacroiliac problems‎
Whiplash‎
Cut‎
High blood pressure
Numbness / tingling‎
Bursitis‎
HIV / AIDS‎
Rash‎
Skin cancer‎
Nasal congestion‎
Stiffness‎‎
TMJ‎
Headaches‎
Sprain‎
Scratch‎
Varicose veins‎
Sciatica‎
Diabetes‎
Cancer‎‎
Warts‎‎
Lymphatic problems‎
Lymph edema‎‎
Arthritis‎
Bone condition‎‎
Accident‎
Bruise‎‎
Circulatory problems‎
Blood clots‎
Tendonitis‎
Hepatitis‎
Seizures‎

Please take a moment to read and initial all of the following statements:

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.‎‎
I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.‎‎
I affirm that I have notified my therapist of all known medical conditions and injuries.‎‎
I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.‎‎
I understand that massage is entirely therapeutic and non-sexual in nature. Any and all sexual behavior will NOT be tolerated and will cause the session to be terminated and payment in full will still be required.‎‎
By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.‎‎
I understand that should I cancel an appointment less than 24 hours before the scheduled time or “no show” an appointment, I am subject to a fee equal to the cost of the missed appointment. This fee is monetary and will be the full price of the scheduled session. If the appointment was booked under a gift certificate, it will be voided in lieu of the fee.‎
Information and Suggestions • Prior to your massage, please remove all jewelry. • In general, massage is given while you are unclothed. However, you may choose to wear undergarments or a swimsuit. You will be covered with a top sheet throughout your session. This is your massage and you should be as comfortable as possible. • Feel free to ask your therapist any questions before, during, or after the session. Your therapist is a highly trained professional and will be happy to make you feel informed and comfortable.‎‎
I have received the policy statement, and have read and agree to the policies therein.
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