Membership Form 1Personal Info2Massage History3Health History Would you like to include the Clinical Health Intake Form with your Membership Form?* Yes No By selecting "Yes" you will be able to continue with the Clinical Health Intake Form on this page.Personal InfoName* First Last Membership Description: You (the member) are agreeing to an auto-renewing monthly massage program with us (Peak Performance Massage). You are agreeing to being a member for a minimum of 90 days with a 30 day written cancellation required in order to terminated your contract. The program also allows you to receive any additional massages during the month at your member rate as well as the ability to purchase gift certificates at that same rate. Any unused massage sessions will roll over into the following month. Any massages remaining after canceling your membership you will have 60 days to use or you can convert them into gift certificates for $15. Any unused massages after the 60 days will be forfeited. If your auto-payment is declined you have 30 days to contact us and set up payment or we hold the right to cancel your membership and forfeit any massages that remain on your account. All other practice policies apply regarding rescheduling and canceling your appointment.Your Membership of Choice* 25 Minute Massage ($40 per month) 55 Minute Massage ($70 per month) 85 Minute Massage ($100 per month) Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone (Cell or best contact number)*Phone (Secondary contact - not required)Email* Occupation / Employer Primary Care Provider Primary Care Provider PhoneEmergency Contact* First Last Emergency Contact Phone* Massage History / Treatment InformationHave you ever received a professional massage?* Yes No Date of last massage MM slash DD slash YYYY What results do you want from your sessions?Please check any areas of your body where you prefer not to receive massage: Head Face Neck Arms Chest Abdomen Back Buttocks Legs Feet Other Other Are you currently seeing a healthcare practitioner?* Yes No Please describe:List stress Reduction and Exercise Activities. Please include frequency.List current Medications, Herbals & Supplements and reason for use. Please Include OTCs such as Aspirin, Ibuprofen, Claritin, etc. Previous HistorySurgeries (Include year and treatment received)Accidents (Include year and treatment received)Health HistoryMusculoskeletal Bone or Joint Disease Tendinitis / Bursitis Broken / Fractured Bones Arthritis / Gout Jaw Pain / TMD Lupus Sprains / Strains Low Back, Hip, Leg Pain Neck, Shoulder, Arm Pain Headaches, Head Injuries Spasms/Cramps Other Other Circulatory Heart Condition Varicose Veins / Phlebitis Blood Clots High / Low Blood Pressure Lymphedema Thrombus / Embolism Other Other Respiratory Breathing Difficulty / Asthma Emphysema Sinus Problems Allergies Other Specify Allergies Other Nervous Herpes / Shingles Numbness / Tingling Pinched Nerve Other Other Reproductive Pregnant Ovarian / Menstrual Problems Prostate PMS Other If pregnant, Trimester: Other Skin Allergies Rashes Athletes Foot Herpes / Cold Sores Warts Other Specify Allergies Other Digestive Constipation Gas / Bloating Diverticulitis Irritable Bowel Syndrome Ulcers Other Other Other Cancer / Tumor Diabetes Chronic Fatigue Chronic Pain Eating Disorders Sleep Disorders Bladder / Kidney Ailment Drug / Alcohol Addiction Caffeine / Tobacco Addiction Migraines / Headaches Anxiety / Stress Syndrome Depression Contact Lenses Consent and Contract for CareIt is my choice to receive massage therapy or yoga, and I give my consent to receive treatment. I have completed this form to the best of my knowledge and will inform the massage therapist or yoga instructor or any changes in my physical health. I understand that massage therapist and yoga instructors can not diagnose illness, disease, or any other medical, mental, or emotional disorder. Nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I realize that the treatment is being given for the well being of my body, mind and spirit. This includes stress reduction, relief from muscular tension, spasm or pain, also for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my wellbeing is compromised. I acknowledge that massage and yoga are not substitutes for medical examinations or diagnosis; I am responsible for consulting a qualified physician for any physical ailments that I have. I understand that massage therapy and yoga is a therapeutic health aide and is non-sexual. Consent* By checking this box I agree to the above statement.