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Massage intake form
Please fill out the following form in order to make your first appointment. Thisonly needs to be submitted once.
Have you had a recent major surgical procedure or injury?
Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?
Are you allergic to any lotions or oils?

I understand that a massage therapist does not diagnose disease, illness, or prescribe any treatment or drugs,  nor do they provide spinal manipulation. I understand that draping will be used at all times.

 

I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the massage session, and they will end the session. I understand that the massage Therapist may end the session for any inappropriate behavior. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status. 

The undersigned (“Client”) hereby freely consents to receipt of massage services.

Client agrees as follows: 

Client understands and agrees that they will provide the Therapist with complete and accurate health  information, and a written referral from Client’s primary healthcare provider if Client is currently receiving  care or has a specific medical condition or symptoms for which Client takes medication or receives periodic  evaluations or treatment. Client understands that massage therapy is designed to be an ancillary health aid  and is not suitable for primary medical treatment for any condition. 

1. Client and Therapist have discussed the potential benefits and possible side effects of massage therapy and have agreed upon a course of focused attention and manual therapy for the predetermined goals of  stress reduction, relief of muscular discomfort, and/or promotion of general health. Client has been  given an opportunity to ask questions of the Therapist and has received all requested information. 

2. Client understands that the unclothed body will be draped at all times for warmth, sense of security, and  as a mark of massage therapy professionalism. Client agrees to immediately inform the Therapist of any  unusual sensation or discomfort so that the application of pressure may be adjusted to Client’s level of  comfort. Client understands that massage therapy is not sexual in any manner and that any illicit or  suggestive remarks or behavior on the client’s part, will result in an immediate termination of the  therapy session. Client understands that payment will be expected in full; regardless if the massage is  completed or not. 

3. Client hereby assumes full responsibility for receipt of the massage therapy, and releases and discharges  Therapist from any and all claims, liabilities, damages, actions, or causes of action arising from the  therapy received hereunder, including, without limitation, any damages arising from acts of active or  passive negligence on the part of the Therapist , to the fullest extent allowed by law. 

4. Client, in signing this consent for Therapy and Waiver of Liability (“Consent”), understands and agrees  that this Consent will apply to and govern the current and all future therapy sessions performed by  Therapist 

5. Once an appointment is made a 24-hour cancelation fee is due. Full payment will be made if canceled after this period. Any late arrivals will be billed the full booking amount.

Thanks for submitting!

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