Custom Massage Therapy of Kannapolis
Client Intake Form
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.
Parent Consent if minor:________________________________________________________________________