Dori White Massage Therapy | (503) 957-3696 |New Patient Intake Form Portland, OR

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

How would you like to be notified of massage specials, discount offers, new services and updates? *

Email Mail None of Above

Primary Phone *

Secondary Phone *

Work Phone *

Date of Birth *

Age *

Gender *

Male Female Other

Occupation *

Where and How Long? *

While at work, How do you use your body?? *

Is this your first massage? *

Yes No

Do you receive massage regularly? *

No Yes

How often? *

How did you find me? *

Who can I thank for your referral? *

How interested are you in making massage a regular part of your healthcare? *

Generally speaking, what type of massage are you interested in today? *

How often does your pain/discomfort bother you? *

Which of the following statements are most true about your discomfort? *

What part/parts of your body shall we focus on today? *

Please be specific about the onset of your discomfort, how long has it been going on? *

On a scale of 1-10, please rate your pain/discomfort today *

Are you under the care of any type of doctor for the conditions we are addressing today? *

Please check all that apply below

Please list medications, vitamins or supplements you use and what you use them for.

Do you have any open wounds, cuts or sores? *

No Yes

Where is your sore/wound? *

Are you currently under the care of any physician for anything other than regular checkups not mentioned above? *

Yes No

Are you Pregnant? *

Yes No

How many weeks along? *

I understand that the above information will be kept in strict confidence and is provided to Dori White LMT in order to receive the best possible care and service. I understand that Dori makes no medical claims and is not liable for any injury, health impairment or accident that may occur during my treatment.

24-Hour cancellation notice is required to avoid paying no show fees.

"No-Shows" are charged the full amount of the missed appointment

Late Arrivals , your session may need to be shortened to accommodate other clients who have made appointments. You will be charged for a full session.

Returned Check Policy, you will be charged $35.00 NSF fee.

New Patient Intake & release Form

Cupping Therapy and Massage Therapy

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