Wild Rose Healing House LLC Intake

Client Intake Form

*First Name
*Last Name
*Email
*Mobile Phone	( ) -
*Birthday
*How did you hear about us?	Business Card Facebook Google Other Sign Trip Advisor Word of mouth Yelp
*Anything contagious
*Cold/Flu
*Acute Injury/Bruises
*Numbness
*Open cuts
*Sunburn
*Skin Rash
*Severe Pain
*Are you allergic or sensitive to fragrances or skin care products?	No Yes
*Have you had surgery or major injury in the past?	No Yes
*If you answered "yes" to any of the above questions, please explain:
*Are you pregnant?	No Yes
*Months Pregnant
*Please list any areas of the body that you would like us to FOCUS on:
*Please list any areas of the body you would like us to AVOID:

Terms & Conditions

Before my appointment I will screen myself for symptoms including fever and cough and will not come to my appointment if these symptoms are present, and will not reschedule until they clear up.
I hereby release and forever discharge Wild Rose and the employees that work there of any unfortunate and highly unlikely injury or illness that may occur as a result of your treatment.
All massages are draped, following a professional code of conduct & ethics.
Sexual remarks or advances will terminate the session with client liable for payment of the scheduled treatment.
Clients that arrive intoxicated / inebriated will be denied treatment, with client being liable for the full payment of scheduled treatment.
I will inform my therapist of any changes in my medical status.
I will inform my therapist if I need the pressure to be adjusted, or experience any pain or discomfort during my massage.

Cancellation Policy

A 24-Hour notice for rescheduling or cancellation is required. Wild Rose reserves the right to charge the full treatment cost for reschedules and cancellations made with less than 24 hours notice. This includes appointments that are scheduled within 24 hours of the appointment time. If you cancel from within your online account and do NOT receive a text or email confirmation, you are required to contact us directly for guaranteed cancellation to ensure that you are not held liable for any charges. Cancellations must be communicated directly to the front desk. Email cancellations will not be accepted. If you have a contagious illness or skin condition, please adhere to our cancellation policy in order to not put our therapists at risk.

Late Policy

Appointment start times are prompt. It is recommended that you arrive 10-15 minutes prior to your appointment start time. If you are NEW clients you must complete and submit the Client Intake Form which can be done upon your arrival or in advance via our website. Arriving more than 15 minutes early may result in a wait, while arriving later than your appointment start time will result in a shortened appointment time. If you miss more than half of your scheduled treatment, your appointment will be treated as a late cancellation and service will not be conducted and you will be charge in accordance to the cancellation policy.

We adhere to our policies as a courtesy to other clients and our staff.

By checking the box below, I certify that I am the above named person, that the above information is accurate, that I agree to the above terms and conditions and I understand that because massage should not be done under certain medical conditions, I have answered all questions pertaining to medical conditions truthfully. I forever release Wild Rose of any unfortunate and highly unlikely event of injury resulting from any and all agreed therapeutic services. I also agree to the terms and conditions, cancellation policy and late policy.

I agree to the terms and conditions, cancellation policy and late policy