Client Form

Please complete the form below or download a printable Client Information Form

Are you taking supplements, vitamins or additional nutritional support? yesno

Do you stretch or utilize posture therapy of any kind? yesno

Do you have any of the following:
Frequent headaches?Backaches?Cancer?Osteoporosis or osteopenia?Athlete's Foot?Contagious or infectious disease?Phlebitis?High blood pressure?Currently pregnant?Circulatory problems or cardiac problems?Diabetes?Epilepsy or seizure disorder?

Past surgery? yesno

Tension or soreness? yesno

Previous massage or bodywork? yesno

Do you drink alcohol? yesno

Take prescription medication? yesno

Do you consume sugar? yesno

CANCELLATION/RESCHEDULE POLICY: We absolutely appreciate your business however we must charge for missed appointments. Due to the large amount of time that must be blocked out for each appointment, the full fee will be charged for appointments or cancellations with less than 48 hour notice. Please do not come in if you are ill.

Contract for Care: I certify that the above information is true and accurate to the best of my knowledge, and I agree to keep my appointments in a timely manner. I agree to pay for cancellations, reschedules, or no-shows with less than 48- hour notice. I forever release all liability from Back In Balance, Nitasha Canine, and her associates. I agree to keep the therapist informed of any changes that develop over the course of our therapeutic relationship.