Wellshrine Intake Form (Required by all first-time massage clients)

Massage Client Intake/Consent Form

First Name

Date of birth

Date

Last Name

Referred by

Email Address

example@example.com

Mobile Phone #

Home Phone #

Work Phone #

Address

Street Address

Street Address Line 2

CityState

Zip Code

Emergency Contact name

Emergency contact relationship

Emergency phone #

Physician's name

Physician's phone #

Date of initial visit

Date

How would you rate your general health?

Have you ever had a professional message before?

If yes, date of last treatment:

Date

List current medications & the conditions they are treating

List any major accidents or surgeries (including dates)

Date

Please tell us about any allergies or hypersensitivities

Reason for initial visit

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HEAD NECK

CARDIOVASCULAR

RESPIRATORY

SKIN & INFECTIONS

NERVOUS SYSTEM

OTHER CONDITIONS

MUSCULOSKELETAL SYSTEM

REPRODUCTIVE

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. 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. 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 confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.

Signature:

Date:

Date