Connection Studio — Unique atmosphere, unique approach

New Client Intake & Consent

Connection Studio · Amy Zukoff, LMT · 23 Claremont Ave, Buffalo, NY 14222 · 716.939.1142

Please complete before your first visit. Feel free to fill it in on paper, or type and print.

Client Information

Name Date of birth Today's date Address Phone Email Occupation How did you hear about us? Emergency contact Emergency phone

Health History

Please check any conditions that currently apply or have applied to you.

Current medications Allergies (including oils / lotions) Areas of pain, tension, or injury to focus on Areas to avoid Are you under a physician's care? If yes, for what?

Pressure preference: Light Medium Firm Adjust as we go

Informed Consent

I understand that the massage therapy provided at Connection Studio is for stress reduction, relief of muscular tension, and general wellness. The therapist does not diagnose illness or disease or prescribe medication, and massage therapy is not a substitute for medical care. I have disclosed all known medical conditions and will report any changes to my health.

I understand that I may stop the session, decline any technique, or adjust pressure at any time, and that I will remain appropriately draped throughout the session. I take responsibility for communicating my comfort level during the session.

Client signature Print name Date

Studio Policies

Payment is due on or before the date of your appointment.
Accepted methods: cash, check, or card — in person or by mail.
Returned checks are subject to a $35 fee.
Cancellations require at least 24 hours' notice. Missed appointments or late cancellations are charged the full appointment fee.
Please arrive a few minutes early so your session can begin on time.

I have read and agree to the studio policies above.

Client signature Date