Client Intake Form

Name *
Name
Address *
Address
Home Phone *
Home Phone
Cell Phone *
Cell Phone
Emergency Contact *
Emergency Contact
Emergency Contact Phone Number *
Emergency Contact Phone Number
Do you struggle with any of the following?: *
Current physician/therapist:
Current physician/therapist:
If necessary I allow Scott Lyons to discuss with my health care provider the appropriateness of bodywork for my condition, and I understand that bodywork is not a replacement for medical treatment. I release Scott Lyons from any claim or injury resulting from any act or omission during therapy/session. I understand that I am responsible for full payment if I cancel with less than 48 hours notice. By entering my name and date below I am digitally signing this document. *
If necessary I allow Scott Lyons to discuss with my health care provider the appropriateness of bodywork for my condition, and I understand that bodywork is not a replacement for medical treatment. I release Scott Lyons from any claim or injury resulting from any act or omission during therapy/session. I understand that I am responsible for full payment if I cancel with less than 48 hours notice. By entering my name and date below I am digitally signing this document.
Today's Date *
Today's Date