Initial intake form Including Acknowledgements, Consent and Release of Liability
Please fill out the form. The information provided below or during your massage therapy session will be kept confidential and will be used only to provide you with the best health care services possible.
Email *
First & last name *
Year of birth *
MM
/
DD
/
YYYY
Weight *
Emergency contact name & phone number *
What are the main thing's you'd like to work on during your massage? *
Please specify areas of pain / discomfort & which side of the body?
Below are conditions that are contraindicated to Massage therapy. Please check all that apply
Health History. Please check all that apply.
Any recent injury / surgery / inflammation ? Please specify location and when it happened.
Any Herniated disc ? Please specify location and when it happened.
Any limited range of motion or areas that can not be stretched ? Please specify location.
Please sign document by typing your Initial * *
Today's Date *
MM
/
DD
/
YYYY
CANCELLATION POLICY *
Please be courteous that when you miss a scheduled appointment, it is very difficult for me to make up that loss of time and income. I require 24 hours notice for cancellation or reschedule. Anything less than that I will expect full payment for the missed session.
Required
LATE ARRIVAL POLICY *
If you arrive late for your appointment, your session will still end at the scheduled time and full payment will be expected. Late cancellation due to emergency, illness, or inclement weather will generally not result in a missed session charge but this will be determined on a case by case basis.
Required
INFORMED CONSENT *
I have completed this health form to the best of my knowledge. I understand that massage therapy is a therapeutic health aid and is non-sexual.I am aware of the benefits and risks of the services, assume any and all risks associated there with and voluntarily give my consent to receive the services from Fermin Andujar, Licensed MassageTherapist.I understand that there is no implied or stated guarantee of success or effectiveness. I acknowledge that the Licensed massage therapist does not diagnose illness, disease or any otherphysical or mental disorder, nor do they prescribe medical treatment , pharmaceuticals or spinal manipulation. I understand that Massage therapy cannot safely be performed when certain medical conditions exist and that it is recommended that I see a primary health care provider for that service. I waive release, discharge and hold harmless Fermin Andjar, LMT from any and all liability for any injuries, damages or claims relating to or resulting from my receipt of the services. I acknowledge that I have read, and understand, the release and indemnification provisions set forth the preceding paragraphs and agree to such terms.
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy