• Massage and Yoga Therapy 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. 




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









  • Specfic Medical Conditions

    If you have ever had any of the following please check P for “past”, C for “current” or N for “no”

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  • Massage Policies and Agreements 


    Client services and information are confidential. Written authorization is required from you to release any information to other healthcare providers, insurance, or other individuals. 

    • Please turn off your cell phone prior to entering the treatment room.
    • 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 

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

    I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. 

    All information provided here is current and complete. I understand that my failure to disclose any medical condition may pose a threat to my health and well-being and I hold harmless Robin Lamperti from any liability whatsoever arising from failure on my part. 

    I agree that all the information provided is accurate and complete, and I agree to the massage policies and client agreement as stated above. 

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