Cause+Medic Spa Massage Intake Form
Email address *
First Name *
Last Name *
Today's Date *
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Email *
Phone *
Address *
City, State Zip *
Date of Birth *
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Emergency Contact Name *
Emergency Contact Phone *
Employer *
Occupation *
How did you hear about us? *
Have you ever received a professional massage? *
If yes, what kind?
What is your reason for visiting today? *
What are your goals for your Massage Therapy session? *
What areas would you like your Massage Therapist to focus on? *
Do you have any prior injuries / surgeries? *
Have you been under the care of a physician or other medical professional within the past year? If so, please explain.
Please list any medications, supplements, or herbal/homeopathic remedies you currently take. *
Do you have any allergies? *
Are you bothered by scents, oils or lotions? If yes, please explain.
Have you ever had an adverse reaction to a cosmetic product? *
If yes, please explain.
Are you pregnant? *
When did you last consume alcohol? *
On a scale of 1-10, how would you rate your current stress level? *
low
high
Please check all that apply to you: *
Required
I certify that the above information is accurate to the best of my knowledge, I have stated all known medical conditions, and I freely give my permission to be massaged. I acknowledge that Massage Therapy cannot cure, treat, prevent, or diagnose any condition. I agree to inform the Massage Therapist if I experience any pain during the session. Information exchanged during any session should be given at your own discretion. I understand that inappropriate comments or conduct will not be tolerated, and any indication of such behavior will automatically end the session. I agree to keep the Massage Therapist updated as to any changes in my health prior to any future sessions and understand that there shall be no liability on the Therapist’s part nor on the part of Cause+Medic Spa and its affiliates should I fail to do so. I agree to hold harmless the establishment, all management, including volunteers, from and against any and all claims. I understand the Massage Therapist reserves the right to refuse service to anyone for any reason. I fully understand that the Massage Therapist is not a doctor, dermatologist, or psychiatrist and does not portray themselves to be. By signing below I acknowledge that I have read and understand all parts of this consent/intake form and that I have had the opportunity to ask any questions with regard to any services or therapies offered. All client information is confidential. Digital Signature (full name): *
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