Custom Massage Therapy of Kannapolis

Client Intake Form

Name:____________________________________________________DOB:________________

Address:______________________________________________________________________

Email address:___________________________________Phone:_________________________

Occupation:____________________________        Have you had a massage before?           Yes    No

 

Were you referred by someone?  No      Yes, by whom?_________________________

Do you have sensitive skin, or allergic to nuts or oils?    Yes          No

What pressure do you like?        Light             Medium/Firm           Deep

 

Where are your problem areas :

Do you have any health conditions such as:

Heart condition               Diabetes              Skin Conditions                Seizures               Migraines

Allergies              Pregnant             Emotional Issues/Depression                  Other:  ____________________________

 

I understand that massage therapy is intended to enhance relaxation, reduce pain caused by muscle tension, increased range of motion, improve circulation, and offer a positive experience of touch.

The general benefits of massage possible contraindications to massage have been explained to me. I understand that massage therapy is not a substitute for medical evaluation, diagnosis, or treatment.  My therapist will alert me to any findings noted during the evaluations and therapy that may require further medical evaluation.

I understand that massage therapy is not sexual in nature and any inappropriate comments, physical touch, or behavior will result in immediate termination of the session.  By initializing below, I indicate my consent to receive the massage therapy services agreed upon.  *No shows will be charged for the full amount and will have to prepay before next appointment can be scheduled. 

 

Patient Signature:____________________________________________________Date:______________________

Parent Consent if minor:________________________________________________________________________