Wild Seed Wellness Massage Client Intake Form

All information is kept confidential.
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    Client Personal Information

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    Health History

    In order to plan a massage session that is safe and effective, we need some general information about your health history. Please answer the questions to the best of your knowledge.
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    This is a good time to take a deep breathe and let it out slowly. Be thankful for your health.
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    Optional Information for Research, Funding and Resource Dissemination

    The following questions are for statistical information and will be used in the future to support researching and funding opportunaties, specifically related to queer and trans people of color, massage therapy and natural healing. This information will remain confidential. Your name will not be attached to this information without your consent. These questions are entirely optional. Feel free to answer as detailed as you wish. If you wish to skip ahead to the Client-Therapist Agreement and submit your intake form, scroll down to the bottom of this page.
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    Client-Therapist Agreement

    I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension, spasm or pain and to increase circulation. If I experience any pain or discomfort during this session, I will immediately inform the therapist 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, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. If I am unable to attend my scheduled appointment, I will respect and abide by the set cancellation policies. Sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated. I understand that I am receiving massage therapy at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever.
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