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404.556.6363
The following forms are meant to Better Serve Your Needs and Deliver the Highest Level of Proficiency with Each Massage! 
Please review, download and complete the forms below, prior to initial appointment/assessment.  
Sweet Earth Therapeutic Massage LLC
Myrna Lovell-Jones, LMT, CMT
1575 Old Alabama Rd - Ste 105
Roswell, GA 30076
404-556-6363
Email: info@sweetearthmassage.com
www.sweetearthmassage.com

CLIENT's  INTENDED  OUTCOME FORM

Full Name:____________________________________________________ DOB: ____________________

Phone #: _______________________ Email: ____________________________________

Occupation: ___________________________________

List the specific goals you’d like to accomplish during our time together:
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Describe the level of health you’d like to be experiencing one year from today:
_________________________________________________________________________________
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Describe any lifestyle changes that you think would help you achieve that goal:
_________________________________________________________________________________
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Client Signature: ___________________________________________          Date: ______________
Sweet Earth Therapeutic Massage LLC 
Myrna Lovell-Jones, LMT, CMT
1575 Old Alabama Rd - Ste 105
Roswell, GA 30076
404-556-6363
Email: info@sweetearthmassage.com
www.sweetearthmassage.com

CLIENT CONSENT FORM

I,___________________________________, understand that massage therapy provided 
  Printed name

by, Myrna Lovell-Jones, LMT, CMT; (hereafter, known as Massage Therapist and/or Practitioner,) 
is intended to enhance relaxation, reduce pain caused by muscle tension, increase range
of motion, improve circulation and offer a positive experience of touch. Any other intended purposes
for massage therapy are specified below:                                                                                                _________ 
                                                                                                                                                             Initials
The general benefits of massage, possible massage contraindications and the treatment procedure have been explained to me. I understand that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I can currently work with my primary care giver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not part of massage therapy.                                                                                                                                                              _________ 
                                                                                                                                                             Initials

I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes. I understand that there shall be no liability on the practitioner’s part due to my neglect in relaying any pertinent information.
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                                                                                                                                                             Initials

If I experience any pain or discomfort during the session, I will immediately communicate that to the therapist so that treatment can be adjusted.                                                                                                                      _________ 
                                                                                                                                                             Initials

I understand that no inappropriate comments or conduct will be tolerated and that any indication of such will automatically end the session.                                                                                                                                                                                                                                                                                                _________ 
                                                                                                                                                             Initials
I further agree to hold harmless the practitioner/massage therapist against any and all claims.
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                                                                                                                                                             Initials
____________________________________           ________________
Client Signature                                                    Date
____________________________________           ________________
Therapist: Myrna Lovell-Jones, LMT, CMT              Date
      Sweet Earth Therapeutic Massage LLC 
Myrna Lovell-Jones, LMT, CMT
 1575 Old Alabama Rd - Ste 105
Roswell, GA 30076
404-556-6363
Email: info@sweetearthmassage.com
www.sweetearthmassage.com

CLIENT INTAKE FORM

Full Name:____________________________________________________ DOB: ____________________ 

Phone #: _______________________ Email: ____________________________________ 


Address: __________________________________________________________________ 

City: ______________________________ State: ______ Zip: __________ 

Occupation: ___________________________________ 

Emergency Contact: __________________________________ Phone #: __________________________ 

Relationship: __________________________________________________________________________

Physician: _________________________________________ Phone #: __________________________ 

Medical History: 
Health Conditions: __________________________________________________________________________

__________________________________________________________________________________________


Current Medications: ________________________________________________________

Please indicate any of the following conditions that you currently have by circling: 

Headaches          Allergies           Arthritis         Tendonitis            Abnormal skin condition     Joint surgery

TMJ                    Cancer              Heart/circulation problems         High / Low blood pressure       Diabetes 

Major accident    Varicose veins    Blood Clots       Fibromyalgia    Neck / back injuries           Numbness

Sprains/Strains    Recent Injuries   Epilepsy or Seizures  

Explain Any Conditions You Have Marked Above: __________________________________________
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Do you suffer from claustrophobia? Y N
Do you suffer from stress? Y N
Do you have a contagious disease? Y N
Do you wear a pacemaker? Y N
Do you have chronic back pain? Y N
Do you bruise easily? Y N
Do you take aspirin or blood thinners? Y N
Do you suffer from asthma? Y N
Are you pregnant or nursing? Y N
Have you ever had surgery? Y N
Was surgery performed with the last 30-days? Y N
Do you have any herniated disks? Y N
Any problems with sleeping or sleeping disorder? Y N
Do you exercise/work-out on a weekly basis? Y N 

How do you reduce stress? ___________________________________________________________

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All the above is true and correct to the best of my knowledge, ________________________________.

Printed name
Client Signature: ________________________________ Date: _______________


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Myrna Lovell-Jones, LMT, CMT