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

Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

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

Email Mail None of Above

Today's Date *

Primary Phone *

Secondary Phone *

Work Phone *

Date of Birth *

Age *

Gender *

Male Female Other

Occupation *

Where and How Long? *

Is this your first massage? *

Yes No

Do you receive massage regularly? *

Yes No

How often? *

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

What type of massage are you interested in today? *

Full body relaxation massage Deeper therapeutic area specific massage?

What would you like me to know? *

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

On the chart below shade in the areas of your discomfort or concern, and number them in order of importance.

Regarding the notes you made in the chart above, choose one of the following statements. *

This is a recent, sudden, short-term issue This is a long-term, chronic condition or injury

Above is caused by... *

Mark all that apply below

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

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

Yes No

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

Yes No

3. Are you Pregnant? *

Yes No

How many weeks along? *

If you answered YES to any of the three questions above questions, please tell me a bit more. *

If you answered YES to #2

Physician's Name *

First

Last

Physicians Phone Number *

Is there anything else I should know about that I haven't asked? *

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 of half your scheduled appointment amount.

"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 Form

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