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Client Intake Form

Client Intake Form

Personal Information

Birthday

Reason for Visit

How would you rate your general health?
Have you ever had a professional message?
Yes
No
If so, when was your last massage?

Health History

Cardiovascular
Head & Neck
Musculoskeletal
Neurological
Respiratory
Reproductive
Skin
Miscellaneous

Waiver

Please read and sign:


  • I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.


  • 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 today's services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/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 and 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.


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

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