Intake Form The Boston Bodyworker Intake Form Please complete the following form if this is your initial visit with us OR it has been more than 2 years since your last visit. Thank you. Step 1 of 4 25% Intake Form Please complete this form to help us to provide you with the best possible service and experienceName(Required) First Last Mobile Phone(Required)Email(Required) Are you a guest of the Seaport Hotel?(Required) Yes No Room Number(Required) Please enter your room number and the name the reservation is being held underWhere are you from? City stateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Height (ft)(Required)Height (ft)4567Height (inches)(Required)Height (inches)01234567891011Weight (lbs)(Required)Preferred PronounsChoose your preferencehe/him/hisshe/her/hersthey/them/theirsJust my use my nameD.O.B. (mm/dd/yyyy)(Required) Month Day Year Are you 18 or older?(Required)selectYesNoI understand that I must be accompanied by someone 18 years or older to receive this service.(Required)selectYesNo How did you find us?(Required) Referral (family/friend/coworker) Web search Seaport Hotel/Wave Health & Fitness Social media content Special Event Other Who referred you?(Required) What search words did you use?(Required) This really helps us fine tune our ad reach. TYOther Have you ever had a massage before?(Required) Yes No Thank you for choosing The Boston Bodyworker for your initial massage experience. Please refer to our FAQ page for some answers to common questions. Click hereWhen did you last receive a massage?(Required) Within the past few weeks Within the past few months Within the past year More than a year ago Did you enjoy your last massage?(Required)selectYesNoWhat did you enjoy about your last massage? What did you dislike about your last massage? What is the PRIMARY reason for your visit?(Required) Routine wellness Relaxation/Stress Relief Acute pain or discomfort Chronic pain or discomfort Injury rehabilitation Training Management Other What are you training for? Please tell us about your injury(Required) On a scale of 1-10 (10 being the worst), please rate your level of discomfort(Required) 1 2 3 4 5 6 7 8 9 10 Are you currently under the care of a physician or other professional for this complaint?(Required)SelectYesNoPhysician or professionals name and phone number Are you paying with a gift card?(Required)SelectYesNoHiddenEnter the gift card number Hotel Cancellation Policy(Required) I agree and understandHotel Guests “Late Cancel” or “No Show”: $50 charge to room or credit cardPlease take a moment to review our policies Cancellation Policy(Required) I agree and understand First “Late Cancel” or “No Show” – No Fee. Second “Late Cancel” or “No Show” – 25% fee of the original price of the missed appointment. Third “Late Cancel” or “No Show” – 50% fee of the original price of the missed appointment. Any appointment following these occasions will be subject to a charge of the full fee of the missed appointment. Groupon/Discounted Deals: Groupons (or other Discounted Deals) canceled with less then 24 hour notice are subject to be charged up to the full amount paid. Authorization of a minor(Required) I agree and understandBy checking this box, you agree to be accompanied by an adult at the time of your visit.Recommendations(Required) I agree and understandRecommendation may be given by the Therapist with reference to future treatments, activities, occupational and sleep mechanics. The Therapist neither diagnoses illnesses, disease or any other physical or mental disorder, nor performs any spinal manipulations. At times, one may feel some post- therapy tenderness due to lengthening and compression of connective tissue.Consent To Administer Massage Therapy Services(Required) I agree and understandI agree that the information I have provided is accurate. I understand that the massage services provided by The Boston Bodyworker are provided pursuant to and in accordance to the laws of the state of Massachusetts governing massage therapy and that a full and complete medical disclosure is essential in providing such therapy. By signing this release form, I hereby declare that the information I have given is accurate and true. I have disclosed any information that may prohibit me from receiving a massage. I agree to inform The Boston Bodyworker if there are any changes in my health history. I expressly give my permission for The Boston Bodyworker to provide such therapy. I agree to hold harmless, release and indemnify The Boston Bodyworker against any and all liability arising from the application of massage therapy.Signature(Required) Date(Required) MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
