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First name
*
Last name
*
Email
*
Phone
*
Occupation
*
Birthday
*
Month
Day
Year
Emergency name & contact information
*
Are you under the care of a physician? If so, why?
*
Have you ever worked with a body worker before? If yes, how often? What kind?
*
Are you pregnant?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Were you referred by someone? If so, please provide their name
*
Have you broken any bones in the past 2 years? If so, which ones?
*
What pressure do you prefer?
Light
Medium
Deep
How many hours do you sit a day?
*
What are your current issues and for how long?
*
What movements provide discomfort or tightness?
*
Are you allergic to any fragrances and/or scents? If so, please state which ones.
*
4. Do you have some concerns about breathing? What about during exercise?
*
What type of music station or playlist helps you unwind?
To help with scheduling, please select the type of environment you prefer for your stretch sessions. All sessions include the same protocol, care, and attention - this just helps us place you in the best available time slot.
*
Quiet Setting - I prefer calmer, more private environment (limited availability)
Active Setting - I don't mind some activity of background noise in the space (this option provides the most flexibility in scheduling).
No preference
What is your preferred method of contact?
*
Call
Text
Email
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