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Massage Client Intake Form - First Appointment 

  • Waiver
• I understand that massage therapy is provided for stress reduction, relaxation, relief from
muscular tension, and improvement of circulation and energy flow.
• If I experience pain or discomfort during the session, I will immediately inform my therapist so that
pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible
for any pain or discomfort I experience during or after the session.
• I understand that today's services are not a substitute for medical care and that my therapist is not
qualified to diagnose, prescribe, or treat physical/mental illness.
• I affirm that I have notified my therapist of all known medical conditions and injuries.
• I agree to inform the therapist of any changes in my health and medical condition and that there
shall be no liability on the therapist's part should I forget to do so.
• I understand that massage is entirely therapeutic and non-sexual in nature.
• By signing this release, I waive and release my therapist from any liability, past, present, and
future, relating to massage therapy and bodywork.

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First and last name : *
Birthday : *
Gender : *
Email address: *
Phone number : *
Occupation : *
Referred by : *
Emergency contact name and  phone number : *
Reason for Visit *
Describe injuries, concerns, or issues to address + causes and dates of occurrences: *
Health History : *
Signature : *
Date: *
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