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Address:  1330 New Hampshire Ave # B2,
NW Washington, DC 20036


Tel:     202-643-9001

 

Text:     202-643-9001

Email:     thaitastik@gmail.com

Web:     www.Thaitastik.com

Please make an “X” over areas of Stiffness

_______________________________________________________________________________


Thaitastik Client Intake form

Date of Birth________/_______/_______

Cell: (________)______________

Please circle your answer

Sex   Male   Female

Is this your first Thai yoga body work?   (Yes )   (No)

Are you pregnant?   (Yes )   (No)   if yes, how many weeks?_______

Do you have a spinal or herniated discs problems? (Yes )  (No) if yes describe______________

Recent surgeries? (Yes )   (No)   if yes, describe where on your body?_____________________

Are you taking pain killer medication?  (Yes )   (No)

I_______________________________________(Print name) understand that I experience any pain or discomfort during my session, I will immediately inform the practitioner. I also understand that Thai yoga body work should not be considered a substitute for a medical or physical illness that I am experiencing. I also understand that certain contraindications exist for body work and I will inform my practitioner immediately if any changes to my health profile occur. I agree that my practitioner will not be held liable for any negative effects if I fail to update my profile or provide complete information. Finally, I understand that any illicit or sexual suggestive remarks or advances will NOT be tolerated and will result in the immediate termination of the session with full payment.


Client’s Signature_________________________Date______/_______/_________________