Enhanced Massage Therapy Intake Form
Date of Birth *
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Full Name *
Your answer
Occupation *
Your answer
Hobbies *
Your answer
What type of pressure do you prefer *
Required
How often per year do you receive professional massage? *
Your answer
What are your goals/expected outcomes for receiving massage/bodywork? *
Your answer
Currently under medical care *
Any Metal Implants, Screws, or Pace Maker? *
Required
Taking Blood Thinners? *
Currently or past 10 days, taken Antibiotics? *
Currently or past 10 days, taken Narcotics? *
Allergic to Nuts, Fruits, Flowers or Trees? *
Required
Please check all that apply: *
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Consent for Treatment: If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. *
Required
Any areas of tension you’d like to focus on today?
Your answer
Include Massage Of: *
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Enhance with: (complementary, choose as many as you’d like) *
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Include these UPhancements with today’s visit: (with availability) *
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