Massage and Bodywork
Intake Form
Client Information
Name
*
First Name
Last Name
Parent's Name (if under the age of 18)
First Name
Last Name
E mail:
*
example@example.com
Date of Birth
/
Month
/
Day
Year
Address
*
Street Address
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
Current Occupation:
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Were you referred to Anointed Hands?
*
Yes
No
If yes, by whom?
Massage and Bodywork Questions
Have you ever received professional massage or bodywork?
*
Yes
No
If yes, how often do you get massages?
Please describe any exercise or movement you do each week.
Health Questions
Please specify any areas of your body affected by injury, ailment or surgery.
*
Any medications, vitamins or supplements?
*
Liability Waiver and Agreement
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 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 th
at 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.
It is my choice to receive massage therapy, and I give my consent to receive treatment.
By signing this release, I hereby waive and release my therapist and Anointed Hand
s Massage Therapy
LLC from any and all liability, past, present, and future relating to massage therapy and bodywork.
I have read the statement above and agree with all the policies.
*
I agree
I disagree
Today's Date:
*
/
Month
/
Day
Year
Submit
Should be Empty: