Sound Therapy: New Client Form

Sound Therapy Massage

07980817790 | www.zogiyoga.com | info@zogiyoga.com
New Client Form
Name*

First NameLast Name
Gender*
Phone Number*

Country CodePhone Number
Email*
Your Birthday*

MonthDayYear
Would you like to hear about new classes and courses by email ?
Address

Street Address

Street Address Line 2

CityCounty

Post Code
How do you prefer for ZOGI to contact you? *
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Country CodePhone Number
How did you hear about us?*

FacebookInstagramGoogle SearchReferral (type name below)Other
How often do you like to get a massage/treatment?*
When was your last massage or treatment?*
What is more important to you?*
What are your current issues & how are they affecting you?*
What type of pain are you currently experiencing?*

Stabbing PainElectrical Pain (Sharp Electric Shock)Burning PainAchy PainWidespread Pain & TendernessMuscle SpasmsTension PainSharp Pain, Localized, Small AreaNoneOther
How did your issue/pain begin?*

SlowlySuddenlyIt has gotten worse over time.It has improved over time.I'm not sure how it happened or how it progressed.N/A I do not have an issue or pain.Other
In your entire lifetime, have you ever had any of the following surgeries?*

Any Orthopedic SurgeryCarpal Tunnel SurgeryRotator Cuff SurgeryNeck / Back FusionKnee SurgeryHip ReplacementAnkle SurgeryGallbladder SurgeryHysterectomyAppendectomy (Appendix Removal)Breast SurgeryLymph Node RemovalOther
Please list all surgeries:
HEAD INJURY: Please list any significant head injuries, like concussions, being knocked unconscious, or traumatic brain injury.*
BODY INJURY: Please list any significant injuries to your joints, muscles, or bones. *
Do you have any special needs I should prepare for?
Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
Which prescription medications are you currently taking?*

I am NOT taking any prescription medications.I just take Aspirin for my heart.I take a blood thinner medication.Other
Medical History: If you have experienced any of the symptoms that are marked with an asterisk (*), please call to discuss your medical history before booking an appointment; this is to ensure your safety and well-being.

Medical History*

	Current	Past	Never
Pregnancy*
Blood Clots*
Pacemaker*
Congestive Heart Failure*
Unexplained Calf Pain*
Varicose Veins*
Stroke or Heart Attack*
Cancer*
Car Accident*
High Blood Pressure
Low Blood Pressure
Epilepsy / Seizures
Chronic Headaches / Migraines
Chronic Dizziness / Ringing Ears
Digestive Disease (IBS, Crohns, etc)
Chronic Constipation
Chronic Diarrhea
Kidney Disease / Chronic UTI's
Arthritis (rheumatoid, osteoarthritis)
Scoliosis / Kyphosis / Lordosis
Osteoporosis
Degenerative Spine / Disk
Broken Bone
Allergies that Require an Epi-Pen
Autoimmune Condition (Celiac, Hashimotos, Lupus, Graves, etc)
Diabetes / Insulin Resistance
Endocrine / Thyroid Condition
Chronic Depression
Chronic Anxiety
Chronic Swelling
Sensitive to Touch / Pressure
Easy Bruising
Shortness of Breath / Asthma
Chronic Muscle / Joint Stiffness
Chronic Muscle / Joint Pain
Chronic Pain
Chronic Numbness / Tingling
Neurological Condition (ALS, Parkinsons, etc)
Chronic Skin Rash
Highly Sensitive to Certain Smells or Fragrances
Fibromyalgia
Multiple Sclerosis
Memory Loss / Confusion

Cancellation Policies

100% Full Payment is required for the following conditions:
- No Show: If you do not show up for an appointment, you will be charged the full cost for the appointment. Payment is due before your next appointment.
- Late Arrival: If you are late to your session you are welcome to receive whatever time is left in your appointment. Due to our tightly booked schedule we are generally unable to extend your session beyond your original appointment time. Regardless of the length of the service actually given, you will be responsible for payment of the full service you scheduled. Please plan to arrive 5 minutes early for your appointment.
50% Payment is required for the following condition:
- Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 50% of the scheduled appointment fee. Payment is due before your next appointment.
Smoke-Free Policy

Smokers are asked to please shower before your appointment and avoid smoking until after your appointment; this helps us avoid the smell of smoke in our office, which triggers migraines and asthma attacks in our most sensitive clients, especially children.
Sickness Policy

Please reschedule your appointment as soon as you are aware of an infectious or contagious condition.

If you arrive for your appointment with symptoms of an illness, you will kindly be asked to reschedule your appointment to avoid the spread of germs. This protects are most susceptible loved ones - children, the elderly, & people with suppressed immune systems, like cancer patients.

If any of the following describes you, I kindly ask that you reschedule your appointment so we can prevent the spread of bugs:
- Fever or Chills
- Vomiting or Diarrhea
- Runny Nose
- Sore Throat or Cough
- You are currently taking an antibiotic.
- You have a skin infection like ringworm or athletes foot.
- You or someone in your direct care has a cold, sinus infection, or flu bug.
- You or someone in your direct care has been diagnosed with influenza (the flu).
Even if you are cancelling your appointment within the 24-hour notice period, the cancellation fee may be waived; the onset of symptoms doesn't always have great timing, right?
Informed Consent
By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read the New Client Intake Form for ZOGI in its entirety.

2. I fully understand all questions and information provided in the New Client Intake Form for ZOGI.

3. I have completed the New Client Intake Form for ZOGI accurately and to the best of my knowledge.
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New Client Form

By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read the New Client Intake Form for ZOGI in its entirety.

3. I have completed the New Client Intake Form for ZOGI accurately and to the best of my knowledge.