Client Intake Form

First name

Last name

Phone

Birthday

Month

Day

Year

Email

Preferred Method of Contact

Text

Email

Call

Address

Referred by:

Gender

Female

Male

Non-Binary

Prefer Not To Say

Have you ever received professional massage/bodywork before?

Yes

No

How recently?

What are your goals and expected outcomes for receiving massage?

List and prioritize your current symptoms and issues:

Do these symptoms interfere with your activities of daily living (e.g. sleep, exercise, work, childcare)?

Yes

No

If yes, explain:

Occupation

How may your job negatively impact your muscles:

Physical History - recent or recurring injuries, surgery history, chronic illnesses that may affect posture:

Select any of the following health conditions that you currently have. If you are unsure, please ask. Please answer honestly, as massage may not be indicated for these conditions:

Massage Consent Agreement

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

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. Massage is not a substitute for medical examination, diagnosis, or treatment. Massage should not be performed under certain medical conditions, and I affirm that I have stated all my known medical conditions.

I agree to keep the massage therapist updated as to any changes in my medical profile during the session and understand that there shall be no liability on the massage therapists part should I fail to do so.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.

I understand that the Certified Massage Therapist reserves the right to refuse to perform massage on anyone whom they deem to have a condition for which massage is contraindicated.

Consent For Treatment

I understand that, because the appointment involves touch and/or close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this contract, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from/work with this practitioner.

I agree to the terms & conditions.

Signature

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