Initial intake form Including Acknowledgements, Consent and Release of Liability

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Please fill out the form. The information provided below or during your massage therapy session will be kept confidential and will be used only to provide you with the best health care services possible.

Email *

First Name & Last Name : *

Address :

Year Of Birth : *

Weight : *

Height : *

Emergency Contact Name & Phone Number:

If you seek massage to address any complaint, what is it ?

When did the issue begin ?

Please specify areas of pain / discomfort & which side of the body?

Below are conditions that are contraindicated to Massage therapy. Please check all that apply

Aneurysm

Thrombosis (Blood clot) including Deep Vein Thrombosis & Pulmonary embolism

Infectious Skin Disease eg Cellulitis , Impetigo

Flu, Pneumonia, Cold, Fever, Covid19

Health History. Please check all that apply.

Allergic to nuts or almond, coconut, jojoba, essential oils or other oils

Auto Immune Disease

Athlete foot

Active cold sore

Cancer

Hernia

Heart Disease / Wearing a peace maker

Whiplash injury

Other:

Any recent injury / surgery / inflammation ? Please specify location and when it happened.

Any Herniated disc ? Please specify location and when it happened.

Any limited range of motion or areas that can not be stretched ? Please specify location.

Any nerve impingement ? Please specify location.

CANCELLATION POLICY

Please be courteous that when you miss a scheduled appointment, it is very difficult for me to make up
that loss of time and income. I require 24 hours notice for cancellation or reschedule. Anything less than
that I will expect full payment for the missed session.

LATE ARRIVAL POLICY

If you arrive late for your appointment, your session will still end at the scheduled time and full
payment will be expected.
Late cancellation due to emergency, illness, or inclement weather will generally not result in a
missed session charge but this will be determined on a case by case basis.

INFORMED CONSENT

I have completed this health form to the best of my knowledge.
I understand that massage therapy is a therapeutic health aid and is non-sexual.
I am aware of the benefits and risks of the services, assume any and all risks associated therewith
and voluntarily give my consent to receive the services from Krittiya Leoviriyakit, Licensed Massage
Therapist.
I understand that there is no implied or stated guarantee of success or effectiveness.
I acknowledge that the Licensed massage therapist does not diagnose illness, disease or any other
physical or mental disorder, nor do they prescribe medical treatment , pharmaceuticals or spinal
manipulation. I understand that Massage therapy cannot safely be performed when certain
medical conditions exist and that it is recommended that I see a primary health care provider for
that service.
I waive release, discharge and hold harmless Krittiya Leovirykait LMT from any and all liability for
any injuries, damages or claims relating to or resulting from my receipt of the services.
I acknowledge that I have read, and understand, the release and indemnification provisions set
forth the preceding paragraphs and agree to such terms.

Please sign document by typing your Initial *

Date *

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