Intake Form
Massage Intake Form for Minter Massage
Email address *
Name *
Your answer
Address *
Your answer
Email *
Your answer
Phone *
Your answer
Date of Birth *
MM
/
DD
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YYYY
Physician or Healthcare Provider
Your answer
Physician Phone
Your answer
Have you had a massage before?
Do you have any difficulty lying on your stomach, back or side?
Do you have any allergies?
Your answer
Please briefly describe your areas of concern.
Your answer
What, if anything, helps the discomfort?
Your answer
What makes the discomfort worse?
Your answer
Please indicate conditions you have or have had in the past. *
Required
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.
Agree or Disagree *
Signed *
Your answer
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