Intake Form

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.

I affirm that I have notified my therapist of all known medical conditions and injuries.

I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.

I understand that massage is entirely therapeutic and non-sexual in nature.

I understand that should I cancel an appointment less than 24 hours before the scheduled time or “no show” an appointment, I am subject to a fee equal to the cost of the missed appointment. This fee is monetary & can’t be taken as an additional “punch” off a massage package card. If the appointment was booked under a gift certificate, it will be voided in lieu of the fee.

Information and Suggestions

Prior to your massage, please remove contact lenses and all jewelry. Pull long hair back with a clip or band.
In general, massage is given while you are unclothed. However, you may choose to wear undergarments or a swimsuit. You will be covered with a top sheet throughout your session. This is your massage and you should be as comfortable as possible.
Feel free to ask your therapist any questions before, during, or after the session. Your therapist is a highly trained professional and will be happy to make you feel informed and comfortable.

I have received the policy statement, and have read and agree to the policies therein.

By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

Name
Email
Address
Phone
DOB
Occupation
Emergency Contact		Emergency phone

General & Medical Information

Have you ever had a professional massage?	If yes how often?
Are you pregnant?	If yes, how far along are you?
Are you sensative to touch/pressure in any area, or ticklish?
Are you allergic or sensative to any oils (essential oils, nut oils, scents)?	If yes please list:
List of current medications and reason:
List of surgeries (type and date):

Pain Chart with scale check all that apply

Head
Neck
Shoulder
Back
Lower back
Elbow
Pelvis
Thigh
Knee
Foot
Heel
Notes and details:

Please check all that apply:
Skin conditions: rash, warts, hives, skin cancer	other:
Lymphatic Conditions: swolen glands, nasal congestion, lymph edema
Joint problems: stiffness, arthritis, sacroiliac, tmj,	other:
Bone Condition: osteoporosis, fracture	other:
Headaches
Recent injury details:
Circular condition: high blood pressure, varicose veins, blood clots.
Numbness, Tingling, Sciatica
Tendonitis, Bursitis, Diabetes

Intake form

General & Medical Information

Pain Chart with scale check all that apply

Waiver Information

How did your symptoms begin and when did they start?
What have you done for relief?
Is the condition getting better or worse?

Intake form

General & Medical Information

Pain Chart with scale check all that apply

Waiver Information

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