New Client Intake Form - EXIGE MEDI SPA

The "Intake Form" is Required in Order to Get Reimbursed by Your Insurance

This form will be used to gather; contact information, medical history, Insurance Carrier details, as well as disclaimer information.

Please take the time to carefully complete this form in it’s entirety as it will be used by the clinic as reference for all of your treatments.

Name*
First Last
Email – Billing*

Used for; appointment confirmations, cancelations, reminders, and insurance receipts
Mobile Phone Number*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Gender*
Date Of Birth*
How did you hear about us?*
Who should we thank personally for this referral?
Insurance Carrier*
Occupation*
1. Have you had a professional massage before?*
- Yes
- No
How often do you receive massage therapy?*
2. Do you have any difficulty lying on your front back, or side?*
- Yes
- No
Please explain*
3. Do you have any allergies to oils, lotions, or ointments?*
- Yes
- No
Please explain*
4. Do you have sensitive skin?*
- Yes
- No
5. Are you wearing any?*
- Contact Lenses
- Dentures
- Hearing Aid
- n/a
6. Do you sit for long hours at a workstation, computer, or driving?*
- Yes
- No
7. Do you perform any repetitive movement in your work, sports, or hobby?*
- Yes
- No
Please describe*
8. Do you experience stress in your work, family, or other aspect of your life?*
- Yes
- No
How do you think it has affected your health?*
- Muscle Tension
- Anxiety
- Insomnia
- Irritability
- Other
Please describe*
10. What is the primary reason for coming to EXIGE?*
11. Are you currently under medical supervision?*
- Yes
- No
Please explain*
12. Are you currently on any diet or nutritional plan?*
- Yes
- No
Please explain*
13. Are you currently taking any medication, herbal supplements or blood thinner?*
- Yes
- No
Please explain*
14. Please check any condition listed below that applies to you:
- Contagious skin condition
- Deep vein thrombosis/blood clots
- Open sores or wounds
- Joint disorder/rheumatoid
- Easy bruising
- Arthritis/osteoarthritis/tendonitis
- Recent accident or injury
- Osteoporosis
- Recent fracture
- Epilepsy
- Recent surgery
- Headaches/migraines
- Artificial joint
- Cancer
- Sprains/strains
- Diabetes
- Fever/flu/cold
- Fybromyalgia
- Swollen glands
- TMJ
- Allergies/sensitivity
- Carpal tunnel syndrome
- Heart condition
- Pregnancy
- High or low blood pressure
- PMS
- Circulatory disorder
- Menopause
- Varicose veins
- Digestive issues
- Atherosclerosis
- Addiction
How many months?*
Please explain*
Please explain*
Is there anything else about your health history that you think would be useful for your therapists and practitioners to know to plan a safe and effective treatment session for you? Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.*
- Yes
- No
I…*
Please enter your full legal name (above)
…understand that the massage, acupuncture and treatment sessions I receive are provided for the basic purpose of relaxation, ease symptoms and relief of muscular tension.

If I experience any pain or discomfort during this session, I will immediately inform the therapists and/or practitioners, so that the pressure and/or treatments may be adjusted to my level of comfort.

I further understand that my treatments at Exige should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment.

I understand that the therapists and practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

I understand that bruising and tenderness can result from my sessions and may cause my body to detoxify, such symptoms may include, but not limited to body aches, drowsiness, etc…

I also understand the effectiveness of my sessions may cause my motor reaction and alertness to be affected, hence I agree not to leave the premises until I am fully alert and conscious of my actions and understand that there shall be no liability on the therapists’ or practitioners’ part should I fail to do so.

Because massage, acupressure and acupuncture should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly.

I agree to keep the spa updated as to any changes in my medical history, profile information and understand that there shall be no liability on the therapist’s, practitioner’s and spa’s part should I fail to do so.

I give permission for therapists and practitioners to discuss my medical history for the purpose of my treatment sessions.

I acknowledge there is a 24-hour cancellation policy in effect. This policy is in place to reflect our commitment to you and ensures that your spot is never given to someone else. If you need to reschedule or cancel, simply notify us by email, text message or phone call, 24 hours prior to your appointment.

Any cancellation with less than 24 hours’ notice will result in a full charge.
I agree to be bound by the terms set forth in this document*
Signature
Phone
This field is for validation purposes and should be left unchanged.