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Mobile Massage Intake Form
1
Contact Info
2
Home Info
3
Insurance
Contact Information
Name
*
First
Last
Phone
*
Email
*
Date of Birth
*
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Home Info
What type of home do you live in?
*
Single-Family Home
Basement Apartment
Townhouse
Condo/Apartment Building
Is there parking available at a reasonable distance (on the same block) from your home?
*
Driveway
Visitor Parking
On Street Parking
No Parking Available
Do you have any pets?
*
Select...
No
Yes
Such as dogs or cats
List All Pets
*
Name
Species
Does your pet(s) display any of the following behaviours?
If yes to any of the below, your pet must be contained in a separate room during your visit.
Aggressive Behaviour
Growling
Biting
Jumping
Fear/Avoidance
Excessive Barking
Do you smoke in your home?
*
If yes, we ask that you please refrain from smoking in your home for at least 1 hour prior to your visit.
Select...
No
Yes
Do you have an appropriate treatment space in your home?
*
Select...
No
Yes
Please note, we will require a non-enclosed room close to the entrance/exit to your home, such as a living room, dining room, kitchen, den, office, etc. Space must be also large enough to accommodate a portable massage treatment table.
What is your living situation (who do you live with)?
*
Live Alone
Spouse
Children
Parents/Guardians
Roommates
Will anyone else be present during your visit?
*
Select...
No
Yes
Who will be home?
*
Do you have appropriate lighting inside and outside your home?
*
Select...
No
Yes
Insurance Coverage
Do you have insurance to cover your massage?
*
Select...
No
Yes
Policy #
*
Plan #
*
Insured Member
*
Consent
*
I have read and agree to the terms below.
We have a zero-tolerance policy for any form of verbal, physical or sexual harassment. We are also professionally obligated to refuse or discontinue treatment if we suspect that you may be under the influence of drugs or alcohol during your visit. In the instance of any form of harassment or drug or alcohol use, your visit will be terminated immediately, and no refund will be provided.
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