Pediatric Form (0-17)

Child's Name*

Child's Birth Date *

Parent/Guardian's Name*

Primary Phone *

Address*

Parent/Guardian's Email Address*

Child's Primary Care Physician, Clinic Name & Phone Number*

Has child ever received professional massage?*

Yes

Reason for seeking massage therapy*

In order to better address your child's goals, please state your/your child's specific concerns and approximate date of onset *

Has child tried any other treatments for concerns listed above?*

Yes

If yes, please describe

Birth History*

Biological child

Adopted child

Foster child

Was child born prematurely?*

Yes

If yes, how many weeks early?

Were there any postpartum complications with the child?*

Yes

If yes, please describe

Please list any current medications (prescribed and over the counter) or supplements the child is taking and what they are treating. Put 'none' if not taking anything.*

Has the child been diagnosed or treated for any of the following disorders/conditions? Please check ALL that apply.*

Any other medical conditions/concerns not listed above*

Has the child had any accidents, injuries or surgeries in the past 6 months?*

Yes

If yes, please describe

Does the child have any allergies/sensitivities to oils, lotions or scents?*

Yes

If yes, please describe

Please list your child's communication style *

What methods does your child use to manage stressful situations (i.e. self-soothing techniques)?*

Does your child exercise or participate in sports? *

Yes

If yes, please describe

Wavier of Liability and Consent to have Massage*

I agree to submitting intake forms online and waive all claims.

I agree to hold harmless Relax & Be Well, LLC, of all claims, including Andree Strauss, her spouse, her heirs, her property and associations.

I understand that my child's information will not be shared with anyone outside of Relax & Be Well, LLC without my written consent.

I understand that if my child has a specific medical condition or specific symptoms, massage may be contraindicated. A referral from my child's primary care provider may then be required prior to their massage session. If my child experiences any pain or discomfort during their massage, the child or I will inform the practitioner immediately.

I understand that the massage therapist cannot diagnose any medical conditions, but they can recommend seeing a medical doctor or medical specialist with any concerns.

I have answered the above information to the best of my knowledge and will let the practitioner know if anything changes with my child's health history.

Cancellation Policy*

I understand that I will be charged 50% of my child's scheduled service fee if I cancel their appointment less than 24 hours before their scheduled time, with the exception of illness, emergency or inclement weather.

I understand I will NOT be charged if I need to cancel within 24 hours due to COVID-19 symptoms in my child, myself or another member of my household.