Massage Intake Form
Allissa Haines, Massage Therapist
172 E Bacon St. #3, Plainville, MA 02762
First Name *
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Last Name *
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Street Address *
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Town/City *
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State *
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Zip Code *
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Phone number *
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Date of Birth *
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Email Address
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Would you like to receive newsletter via email?
Referred by
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May I thank them for referring you?
The following information will be used to help plan safe and effective massage sessions. It will be kept confidential. Please answer to the best of your knowledge.
Have you had professional massage before?
Do you have an allergies or skin sensitivities to oils or lotions? *
If so, please explain
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Do you sit for long hours at a workstation, computer or driving?
Do you have any particular goals for this massage session?
If so, please explain
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Are you currently taking any medications, prescription or over-the-counter? *
If so, please explain
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Please select any condition below that applies to you *
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Please explain any condition you checked above
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Is there anything else about your health history that you think would be useful for your massage therapist to know?
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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 should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage 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 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.
Understanding all of this, I give my consent to receive care, by typing my name below. *
Your answer
Acknowledgement of cancellation policy
Failure to cancel prior to 2 hours before the start of the appointment time will result in charge for 50% of the scheduled appointment price. If you arrive late, your session may be shortened. You will be charged the full amount of the scheduled session.
Client initials *
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