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Call To Book: (302) 500-1013
Massage Health History
We cannot accommodate guests in their first trimester for massage or any body work
.
Personal Information
Name
(Required)
First
Last
Birthday
(Required)
MM slash DD slash YYYY
Date of Visit
(Required)
MM slash DD slash YYYY
Gender
(Required)
Female
Male
Other
Email
(Required)
Phone
(Required)
Occupation
(Required)
Referred By
(Required)
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Physician Name
(Required)
Physician Phone
Emergency Contact
(Required)
Emergency Phone
(Required)
Reason for Visit
How would you rate your general health?
(Required)
Poor
Fair
Good
Excellent
Have you ever had a professional massage?
(Required)
No
Yes
Last time?
(Required)
Describe injuries, concerns, or issues to address + causes and dates of occurrences
Describe any treatment you've received for these particular issues
Describe your treatment goals
Health History
Cardiovascular
Congestive heart failure
Embolism
Heart attack
Heart disease
Hemophilia
High blood pressure
Low blood pressure
Pacemaker
Phlebitis
Poor circulation
Stroke
Thrombosis
Varicose veins
Family history
Head & Neck
Dizziness
Ear problems
Headaches
Hearing loss
Jaw pain (TMJ)
Migraines
Vision loss
Vision problems
Musculoskeletal
Arthritis
Artificial joint
Bursitis
Osteoporosis
Surgical pin/wire
Tendonitis
Neurological
Epilepsy
Multiple sclerosis
Numbness/tingling
Sensory loss/change
Sciatica
Seizures
Respiratory
Asthma
Bronchitis
Chronic cough
Emphysema
Shortness of breath
Sinusitis
Smoker
Tuberculosis
Family history
Reproductive
Given birth
Gynecological problems
Pregnant
Skin
Bruise easily
Skin conditions
Skin infections
Skin irritations
Miscellaneous
Anxiety
Cancer
Depression
Diabetes
Digestive conditions
Fibromyalgia
HIV/AIDS
Stress
Other
Waiver
Waiver
(Required)
I have read and agree to the above.
• I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
• 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 today’s services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/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 and 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.
• By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.
One Wellness Booking Policy
(Required)
I agree to the booking policy.
Thank you for choosing One Wellness. To provide the best experience for all of our clients, we ask that you review our booking policy before scheduling your appointment.
Appointment Reservations
A valid credit or debit card is required to reserve all appointments. Your card information is securely stored through our booking system and will not be charged at the time of booking unless otherwise noted.
Cancellation Policy
We kindly request at least 24 hours’ notice if you need to cancel or reschedule your appointment.
Cancellations made with more than 24 hours’ notice: No charge
Cancellations made with less than 24 hours’ notice: 50% of the scheduled service fee
No-shows or same-day cancellations: 100% of the scheduled service fee
These fees will be charged to the card on file.
Late Arrivals
If you arrive late, your service may be shortened to avoid delaying the next client’s appointment. You will be responsible for the full cost of the scheduled service.
New Clients
New clients may be asked to complete intake forms before their first appointment. Please arrive 10–15 minutes early to ensure your appointment begins on time.
Gift Certificates
Gift certificates must be presented at the time of service. If a cancellation fee applies, it will be charged to the card on file rather than deducted from the gift certificate unless otherwise requested.
Illness
If you are experiencing a fever, contagious illness, or symptoms that could affect your treatment or the health of others, please contact us as soon as possible. We will gladly help you reschedule your appointment.
Payment
Payment is due at the time services are rendered. We accept major credit cards, debit cards, cash, and other approved payment methods.
By scheduling an appointment with One Wellness, you acknowledge that you have read and agree to this booking and cancellation policy.