Client Intake FormFor massage therapy and Akashic Record Reading sessions with Cornelia Logan LMT/ Certified Akashic Record Guide Name * First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY He She They Occupation Emergency Contact List any serious or chronic illness, operations, chronic virus, infections, or traumatic accidents you have had: Please indicate any areas where you are feeling discomfort: Upper Front Body Mid Front Body Lower Front Body Upper Back Body Mid Back Body Lower Back Body Please indicate any conditions that you have had or currently have: headaches/migraines allergies/sensitivities to oils arthritis/tendonitis cancer/ tumors abnormal skin condition joint replacement/surgery major accidents lack of or reduced feeling varicose veins pregnancy blood clots neck/back injuries diabetes fibromialgia breast augmentation wear contact lenses high blood pressure stroke heart attack colitis HIV pacemaker or titanium implant Please read the following and write your name in the field below to confirm. * I understand that this massage is not a replacement for medical care and that no diagnosis will be made. -I am responsible for paying for any appointment cancellation of less than 24 hours. Thank you!
