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About Brian
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Serving Central NJ since 2004
Home
Services
Massage
Private Yoga Sessions
Group Yoga
Coaching
About Brian
Contact
New Client Form
Please complete the form below BEFORE YOUR FIRST SESSION
Name
*
First Name
Last Name
Date of Birth
*
Address
*
Email
*
Phone Number
*
Occupation
*
How Did You Hear About Us?
*
Emergency Contact Name
*
Emergency Contact Number
*
Please list any medical or health issues we should know about or any areas of focus for our session.
*
What are your primary goals for our first massage session?
*
Check all that apply
Relaxation
Pain Relief
Injury/Surgery Recovery
Training for Athletic Event
When was your last massage?
*
I affirm that I have informed the therapist of all my known health conditions and will keep the therapist updated as to any changes in my medical condition.
*
Yes
No
I understand that any illicit or sexually aggressive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of the scheduled appointment.
*
Yes
No
If I do not call 24 hours before my scheduled appointment to cancel, then I will be responsible for paying Jersey Shore Healing Arts for the missed appointment.
*
Yes
No
Write your name & today's date to confirm your signature
*
Thank you!