New Client Intake — Eagle Vision Therapy

01

About you

First name *

Last name *

Email *

Phone

Date of birth *

Occupation

02

Emergency contact

Contact name *

Contact phone *

Relationship

03

Goals for this work

04

Injuries & pain

Where in your body are you feeling pain, tightness, or restriction right now?

Past injuries or surgeries we should know about

Current pain level today (0 = none, 10 = worst imaginable)

05

Health history

06

Training & lifestyle

Primary sport or activity

Typical training frequency (per week)

Anything else about your work, sleep, or stress worth knowing?

07

Preferences

08

Informed consent

I understand that massage therapy at Eagle Vision Therapy is provided for the purpose of relaxation, recovery, and relief of muscular tension, and is not a substitute for medical diagnosis or treatment.

I understand that I may stop the session at any time, decline any technique, or ask for changes in pressure, positioning, or draping. My therapist will maintain professional draping throughout the session.

I understand that I am responsible for communicating relevant health information and updating my therapist if my health status changes.

I consent to receive massage therapy and understand the information above. *

The information I've provided is complete and truthful to the best of my knowledge. *

I understand the 24-hour cancellation policy. *

Digital signature (type your full name) *

Date *

A few honest questions before we begin.