Massage Intake Form

INTAKE FORM

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. A copy of the cancellation policy, late arrival policy, and Pilates liability waiver is available to you by request. These documents can also be viewed online through your MindBody account. By signing below you are declining a copy at this time.
Full Name*

First NameLast Name
Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number*
E-mail*
Do you have any allergies? If yes, please let your Therapist know before your session.*

Yes, I will tell my Therapist before my sessionNo
Medications
Referred By
List Areas of Discomfort or Pain
Please Check the areas you consent for massage. Please note the area below must be checked in order for our Therapists to address the area of concern.*

FacePecsGlutesAbdomenI do not want any of the above massaged
Do you have any of the following symptoms that are associated with COVID-19?*

FeverCoughShortness of BreathChest PainContact with someone who was COVID positive within the last 7 days.NONE OF THE ABOVE
Client Agreement:

I understand that the massage I receive is provided for the basic purpose of relaxation and rlief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. If uncomfortable for any reason, I understand that I may ask the therapist to cease the massage and the session will end immediately. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a qualified medical professional for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skelatal 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. Draping must be used during the session and only the area being worked on will be uncovered. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and uunderstand that there shall be no liability on the therapist's part should I fail to do so.

By my electronic signature below, I agree to the massage policy and client agreement above.
Signature*

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Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty: