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? *

Internet Search for Massage Internet Search for Cupping Met at a Community Event Word of Mouth

Who can I thank for your referral? *

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. Motor Vehicle Accident Injuries care.

What part/parts of your body needs that specific work? *

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

Mark all that apply below

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

Name of medication #1 *

Name of medication #2 *

Name of medication #3 *

#1 Medication used for *

#2 Medication used for *

#3 Medication used 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.

Dori White Massage & Cupping Therapy

9955 SE Washington St., Suite 303
Portland, Oregon 97216
Phone (503) 957-3696

Rediscover Your Healthy, Pain-Free Body!

Providing Massage Therapy for over 20 years, has been awarded "Best in Portland", offering several massage modalities. Specializing in Cupping Therapy, Deep Tissue Massage Therapy, Motor Vehicle Injury Rehabilitation, Myofascial Release, Trigger Point Therapy, Swedish Massage, Relaxation Massage, and more.

Dori White has been a Portland Massage Therapist offering massage therapy since 1998. Lic. #6904

New Patient Intake Form Dori White Massage & Cupping Therapy

Cupping Therapy and Massage Therapy

Dori White Massage & Cupping Therapy