Client intake | Cajun Hands of Bliss

About you

First name

Last name

Date of birth

Phone

Email

Address

City

State

ZIP

Occupation

Emergency contact

Name

Phone

Health history

Check anything that applies. This is how we keep you safe — it is not a diagnosis.

Details (surgeries, dates, other)

Current medications / supplements

Allergies (oils, nuts, latex, scent)

If applicable — pregnancy week

Physician (optional)

This session

What do you want from the work?

Areas to focus

Areas to avoid

Pressure

LightMediumFirm / deepNot sure — guide me

Have you had professional massage before?

YesNo

How did you hear about us?

Informed consent

Massage therapy at Cajun Hands of Bliss is for wellness, pain relief, and mobility. It is not a substitute for medical care, diagnosis, or prescription. Sessions are professional and draped. Travis may refuse or modify work if a condition makes massage unsafe. You may stop the session at any time.

I have answered honestly and will tell my therapist if my health changes.I understand massage is not medical treatment and I consent to receive it.I understand professional draping and that I may stop the session at any time.

Type your full legal name (signature)

Parent / guardian name (if client is under 18)