Massage Intake Form Please fill out the form below to allow me to prepare for and guide your session to the best of my ability. Thank you! Name * First Name Last Name Preferred Pronouns Date of Birth * Email * Phone * (###) ### #### Emergency Contact / Phone Number Who were you referred by? / How did you find Winnow Wellness? * Session Goals / Specific areas of focus (What are you hoping to accomplish during our session? What areas would you like me to work on?) Please list areas you'd like me to avoid. Please list any surgeries, fractures, sprains, or strains and the date they occurred. Please list any allergies. Select All That Apply * (Please select conditions you are currently or have previously experienced.) Anxiety Arthritis Auto-Immune Conditions Blood Clots Bone Fracture Bursitis Cancer Chronic Pain Chemical Dependency (Alcohol or Drugs) Constipation / Diarrhea Current Contagious Rash Depression Dizziness / Fainting Endometriosis Fibromyalgia Headaches / Migranes Heart Condition Hepatitis High / Low Blood Pressue Insomnia Numbness / Tingling Plantar Fasciitis Pregnancy Scoliosis Seizures Skin Conditions Stroke TMJ Varicose Veins Whiplash None / Does Not Apply Other / Additional Info. (If you'd like to list a condition that is not included, or if there is additional information you'd like to add, please share.) Please list current medications and their purpose. Consent to Receive Massage and Bodywork * It is my informed decision to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. I have completed this form to the best of my ability and I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. By checking "I have read and agree to the terms above," I agree to waive all liabilities toward Briana Nava and Winnow Wellness LLC for any injury or damages incurred due to any misrepresentation of my health history. I have read and agree to the terms above. Cancellation Policy * Please give 24 hours notice to cancelling or rescheduling an appointment. Cancellations less than 24 hours will be charged 50% of the service fee, anything under 12 hours will be charged the full service fee. No shows will be charged the full service fee. I understand and agree to the cancellation poliy. Date * MM DD YYYY Digital Signature * Thank you!