(803) 465-7251

7358 Garners Ferry Rd. Columbia, SC

New Patient Form

All New Patients must complete the form below before their first session and hit (SEND) at the bottom. Please setup an appointment by TEXT after filling out the form. Filling out the intake form does not create an appointment on its own.

New Patient Form.

Please fill out Before Massage Session!

First name and Last name

Phone (Put +1 first)

You agree to be contacted about your appointments by Phone/Text.

I agree to be contacted by Phone/ Text

What website or from where did you find or hear about RobLMT? If referred by someone please include their name.

Are you Active Military, Veteran, or Enrolled South Carolina Student with Valid ID? Choose all that apply.

Yes I am Military/ Veteran

Yes I am an enrolled South Carolina Student.

I am none of these.

Do you have any Health Conditions? Cancer, HIV, Skin Disorder Such as psoriasis, Diabetes, High Blood Pressure, Arrhythmia, Defibrillator installed, Heart Failure, Epilepsy, Nephropathy, Allergic reactions, or any other Diagnosed medical condition?

Yes

If yes please explain which condition(s) / Injuries / Skin conditions / Allergies you have.

In a brief description, Tell me what areas of the body are troubling you.

By checking this box you agree that everything on this form is truthful, and that there could be risks to yourself and the therapist if untruthful and you assume all responsibility for any outcomes as a result of that. You agree that sound recording may be used in session for records, medical note taking and communications between therapist and patient. You agree the therapist reserves the right to terminate the session for any conflicting health issue or lewd behavior, possibly without refund.