DISPERSE WELLNESS: INQUIRY FORM
MASSAGE THERAPY INQUIRY FORM 
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Thank you for your interest in receiving Massage Therapy at Disperse Wellness. Please fill out the information below. We look forward to working with you! 
First and Last Name:
Gender: 
Birthdate:
Phone: 
Occupation:
Address:
City:
State:
Zip Code:
Physician Name:
Physician Phone:
Emergency Contact & Phone # 
Decribe any injuries, concerns, or issues wished to address: 
Current Areas of Pain + Discomfort
Have you ever had Surgery, Physcial Therapy, or Pain Management? If so please list dates and time in treatment. 
Have you ever received massage treatment before?  *
Required
What are your current treatment goals for massage therapy? 
Which treatment would you like to select? *
Please select treatment duration: *
MEDICAL HISTORY: CARDIOVASCULAR
(please check if you currently have or have recovered from any of these conditions)
MEDICAL HISTORY: CARDIOVASCULAR
(please check if you currently have or have recovered from any of these conditions)
MEDICAL HISTORY: HEAD & NECK
(please check if you currently have or have recovered from any of these conditions)
MEDICAL HISTORY: MUSCULOSKELETAL
(please check if you currently have or have recovered from any of these conditions)
MEDICAL HISTORY: NEUROLOGICAL
(please check if you currently have or have recovered from any of these conditions)
MEDICAL HISTORY: RESPIRATORY
(please check if you currently have or have recovered from any of these conditions)
MEDICAL HISTORY: REPRODUCTIVE
(please check if you currently have or have recovered from any of these conditions)
MEDICAL HISTORY: SKIN
(please check if you currently have or have recovered from any of these conditions)
MEDICAL HISTORY: OTHER
(please check if you currently have or have recovered from any of these conditions)
Waiver:
Please read and sign: 
I understand that massage therapy is provided for stress reduction, relaxation, relief from musculat tension and improvement of circulation and energy flow

If I experience pain or discomfort during the session, I will immeadiately inform my therapist so the 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 services are not a substitute for medical careand that my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness/ 

I affirm that I will notify 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 there there shall be no liability on the therapist's part should I forget to do so. 

I understand that massage is entirely therapuedic and non-sexual in nature. 

By signing this release, I waive and release my therapist of any libility, past or present, and future, relating to massage therapy and body work.
 *
Waiver:
Please read and sign: 
I understand that massage therapy is provided for stress reduction, relaxation, relief from musculat tension and improvement of circulation and energy flow

If I experience pain or discomfort during the session, I will immeadiately inform my therapist so the 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 services are not a substitute for medical careand that my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness/ 

I affirm that I will notify 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 there there shall be no liability on the therapist's part should I forget to do so. 

I understand that massage is entirely therapuedic and non-sexual in nature. 

By signing this release (typing name below) , I waive and release my therapist of any libility, past or present, and future, relating to massage therapy and body work.
 *
Today's Date:  *
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