New Patient Health History Intake Form

My goal is to understand you ~ your health history, lived experiences, and how you are feeling so that I can tailor our sessions to your goals, needs, supporting your health & well-being. Thank You for taking the time to complete the form. Your answers help me better serve you. Thank You

To the best of my knowledge the information I’ve provided on this form is true and complete. I will inform Vanessa of any changes in my health. I realize that the treatment is being given for the well-being of my body and mind. I agree to inform my practitioner any time I feel that my well-being is being compromised. I understand that Vanessa Escovar does not diagnose illness nor does she prescribe medical treatment. I, the undersigned release Vanessa Escovar CMT #65246 from any liability associated with my Massage Therapy & Bodywork Sessions.

I acknowledge that Massage Therapy & Bodywork is not a substitute for medical examination or diagnosis.

Fragrances:  Myself and some of my patients are allergic to environmental pollutants, such as perfumes, scented body and hair care products. Please refrain from wearing these to our session together.

I understand that my appointment time is set aside just for me, and that 48-hour notice is required for all appointment changes; if not given, I agree that I am responsible for the session fee. I understand and agree to the fees and billing policies of Vanessa Escovar as described in our communication.

By signing this form electronically and clicking "Submit", you are agreeing to the terms as stated above.