Massage Intake Form
Email address *
Full Name *
Your answer
Mailing Address
Your answer
Cell phone number *
Your answer
Date of birth *
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How did you hear about us?
Your answer
Have you received Professional Massage Therapy in the past?
Goal for Today's Massage *
Your answer
Please List any Medications *
Your answer
Emergency Contact (Name/Phone Number) *
Your answer
Please Check any condition that applies to you *
Required
Pregnancy? (Due Date/any Complications)
Your answer
Do you have difficulty Laying on your Front, Back, or Side? *
Do you have any Allergies to oils, lotions, or ointments?
Your answer
Release Form---By signing this, I agree that I have answered all questions to the best of my knowledge and that I will inform the therapist of any changes in my condition or medication. If I experience any pain/discomfort or would like the pressure adjusted, I will inform the therapist immediately. I understand that a massage therapist cannot diagnosis any illness, disease, or any physical or mental disorders nor can the therapist prescribe any medication and that nothing said in a session should be construed as such. I understand that massage therapy is intended to work in conjunction with my health care, not act as a substitute for medical examination. I understand that it is my responsibility to consult a physician for any ailments I may have.I understand that massage therapy is a therapeutic measure used to reduce stress, muscular tension, and pain. I understand there are no guarantees for recovery and if I am unsatisfied with the progress made with my treatment I will inform the therapist, so he/she may direct me to another treatment. I also understand that massage therapy is non-sexual in nature and any advancement made will terminate the massage.I agree to abide by a 24 hour cancellation notice for any scheduled massage. I understand I may be charged up to the full amount of service for missed appointments or for any cancellations with less than a 24 hour notice. I understand that walk-ins are welcome, but does not guarantee the availability for a massage. I understand that if I arrive late for an appointment, the session will end at the original scheduled time to prevent penalizing another client. However, if the massage therapist is late, he/she will fulfill the scheduled massage length or offer a reasonable compensation. I understand that if I use a coupon during my visit, it is not valid with any other coupons or promotions. I agree that I am of legal age (18 years old) and that if I am not, I agree to have my parent or guardian sign a parental/guardian release form before treatment. I understand that certain conditions or medications may contraindicate (not permit) massage or may require the use of alternate techniques or pressure. I respect the decision of the massage therapist and am fully prepared to reschedule the massage for a later date if requested by the massage therapist. I also understand that massage may be advisable by my physician, but not by a massage therapist. In that event, I agree to provide a written agreement from my physician before proceeding with treatment. ------By entering your Full Name Below You agree to the terms set forth above. *
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