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.

New Patient Intake Form Dori White Massage & Cupping Therapy