Massage Therapy Client Information & Waiver Release Form
Language
  • English (US)
  • Spanish (Latin America)

  • Massage Therapy Client Information & Waiver Release Form

    Please complete this form prior to your appointment
  • Date of Birth*
     - -

  • This is a fill in the field. Please add appropriate fields and text.

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  • Have you taken any trips outside of the country within the past 2 weeks?*

  • Are you ill or have exp flu like symptoms within the past 2 weeks?*

  • Have you been exposed to anyone sick or with Covid-19 within the past 2 weeks?*

  • Are you currently taking any medications?
  • Have you had a recent major surgical procedure/injury?
  • Are you currently seeing a Chiropractor, Physical Therapist, or Physician for any ongoing issue?
  • Do you have a preference to lotions or oils?
  • Are you allergic to any lotions, oils or scents?

  • Client Intake Form

    Check the following conditions that apply to you, past and present. Please add your comments to clarify the condition.
  • Musculo-Skeletal

  • Circulatory/ Respiratory

  • Digestive

  • Nervous System


  • Skin

  • Other

  • I understand that a mask is required for my and the therapist safety. I understand a deposit is required to book all appointments. 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 and that breast massage will not be administered on female clients. I understand that if I or the therapist become uncomfortable for any reason that either shall 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 Massage Therapist of any changes in my status.

  • Date
     - -
  • Should be Empty: