New Client Intake Form

First Name

Last Name

Address: Street *

How did you hear about us? (Tell us who referred you)

Please describe the chief reason for your visit: *

What treatments methods have you tried? *

Did any of the treatments help?

If there is time remaining, please describe any other issues you would like worked on

Do you have, or have you had, any of the following conditions? *

Are there any other health conditions, or recent surgeries, not listed, that we should know about?

Are you taking any Medications that would impact your ability to receive massage therapy treatment? *

If YES, please describe:

Please list any skin allergies you have (Type "NONE" If no allergies) *

Level Up Fitness and Wellness Center comprises Certified Personal Trainers, Licensed Massage Therapists. and Certified Nutrition Coaches. Level Up and their partners do not diagnose or prescribe for medical conditions, or prescribe meals. Level Up cannot provide treatment for a specific condition without a doctor's supervision. All fitness assignments, nutrition consultations, and advice are considered as "recommendations." It is your choice to decide if these recommendations are right for you. Consult with your doctor before seeking massage therapy, or making changes to your nutrition and exercise regimen.

I understand that Level Up Fitness and Wellness Center acquires Certified Personal Trainers, Licensed Massage Therapists. and Certified Nutrition Coaches. Level Up and their partners do not diagnose or prescribe for medical conditions, or prescribe meals. Level Up cannot treat a specific condition without a doctor's supervision. All fitness assignments, nutrition consultations, and advice are considered "recommendations." It is your choice to decide if these recommendations are right for you. Consult with your doctor before seeking massage therapy, or making changes to your nutrition and exercise regimen.

By agreeing to this appointment, you are giving permission to use any photos, progress notes, messages, or content taken by staff, or submitted by client, for advertising. For example: Portfolios, online and print ads, etc. With respect to our clients, we protect any parts of information that include any information personal to the client, including last names, birthmarks, tagging personal accounts, etc. This helps us show our community the value of the services we offer. By signing this agreement, you consent to being added to our email list, to be added to appointment reminders, newsletters and periodic advertising according to your requests. You can unsubscribe at anytime by clicking unsubscribe on the email form.

Signature *

By signing this document, you automatically confirm your upcoming appointment. Please note, this document is required before any in-studio services are performed

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Intake Form Required

In order to approve your appointment, we require the completion of our New client intake form. We look forward to working with you soon!