•                                                Client Intake Form

    All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose. 

  •  -  - Pick a Date
  • History of Pathology




  • Please check any symptoms that apply to you and indicate right or left when applicable:









  • Massage Policies:

    Client services and chart information are confidential. Written authorization is required from you to release any information.

           • Please turn off your cell phone for optimal relaxation

           • Your scheduled session is set aside for you. We do not double book appointments

           • Please reschedule your session if you are more than 15 minutes late

           • 24 hour cancellation notice is required to avoid being charged for your session

           • You will be draped and at no time will genitalia or breast tissue be exposed

           • You will have a consultation with your therapist to discuss your session

           • Should the session require, after your therapist has left the room, you may disrobe to your comfort level

           • I understand that my therapeutic massage therapist or I may end the session at any time for any reason

           • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

     

    Client Agreement:

    It is my choice to receive massage or  Health Consultations as a form of therapy.  Due to Covid 19 I am aware of the benefits and risks of being treated in this office  and give my consent for treatment / consultation . I take full accountability of my immune function knowing others are treated and sharing this healing space. __________  (initial here if in office) 

    I have stated that I am free of any  symptoms of flu illness, cold symptoms , and or symptoms of covid 19 with no fever.  To my understanding I have not been in contact with anyone with Covid 19  within the last 2 weeks or 14 days. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis.___________ (initial here if in office) 
    I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

    I understand that my personal health information will be collected. I understand that all information that I provide will be kept on record and file 3 years or unless required by law. I understand and consent that my medical information may be shared by the various careproviders involved in my care and treatment.

    I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

    I understand that treatment given is designed to address the care and prevention of myofascial pain management, dysfunction along with Lymphatic, Swedish, Ayurvedic and Other modalities of the healing arts.  

    I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.  

    I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

    I understand that my failure to do so may post a threat to my health and/physical well being and I  do not hold Hanusa Msssage Therapy  and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

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

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