Intake Form for the Raindrop Technique

Intake Form for The Raindrop Technique

Personal Information

Name: ______

Home/Cell Phone: ______

E-mail: ______

Address: ______

Occupation: ______

What brought you in today? ______

Have you ever received The Raindrop Technique before? Yes/No

Have you ever used Essential Oils before? Yes/No

Have you received Massage Therapy before? Yes/No

Please help us to keep you safe by providing the following information. Circle all that apply, and then explain in the space provided.

Are you currently taking any medication? Yes/No

______

Are you currently under a doctor’s care for any condition? Yes/No

Doctor Name and Phone Number: ______

Are you pregnant? Yes/No ______

Do you have any allergies or skin sensitivities? Yes/No

______

In the past six months have you had any of the following?

Car AccidentSurgeryCancer

DiabetesHigh/Low Blood Pressure

Heart ConditionsStrokeBlood Clots

HeadachesNeuropathy

FibromyalgiaSerious InjuryArthritis

Other: ______

Please explain if you circled any of the above: ______

By signingbelow you acknowledge that Tracy Ash of Harmonic Body is not a doctor and does not diagnose illnesses/injuries or prescribe medications. She does not claim that she or the services offered treator cure you. If you are currently under a doctor’s care or are taking any medications we recommend that you share with your physician any complementary modalities you choose to try, and any changes you may feel so that they can work with you to adjust your treatment if they deem it necessary. You understand that it is your responsibility to inform Tracy Ash/Harmonic Body upon every visit of any changes to your physical or medical conditions/ or medications.You understand the importance of informing Tracy Ash of any discomfort you may feel during the session so she can adjust accordingly or terminate the session if necessary. You understand that certain conditions are contraindicated and you will be informed at the time of booking if we need a doctor’s release to proceed. You therefore release the company from all liability concerning the above mentioned.

Signature: ______Date: ______