• Client Intake Form

    All information submitted will remain strictly confidential.  At no point is information shared without a client’s consent.  You may choose not to answer any question you feel impinges on personal information you do not wish to disclose.  However, the more you share, the more I may be able to help.  Thank you for your time!

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  • History of Pathology




  • If various symptoms or conditions are present in multiple areas, please indicate which areas of your body are affected and what your experience is like.  Be sure to mention which side of the body is affected or if it's both, when applicable.  

  • Massage Policies

    * All clients' information is kept confidential and will only be released with consent.

           • Please be on time and notify your therapist if you're going to be late to ensure there will be enough time for           your session.

           • 24-hour cancellation notice is expected in order to avoid being charged half the regular rate of the service a               client is scheduled to receive.  Exceptions apply in emergency situations or when someone falls ill.  

           • A consultation will be provided prior to your session to discuss any of your questions and concerns, as well as           identify personal preferences and treatment goals.

           • For optimal enjoyment, it is recommended that you turn sounds and notifications off on your cell phone                     during your session.           

           • You will be modestly draped the entire time and are encouraged to disrobe after the therapist has left the                    room only to a level you are comfortable with.

           • Either the massage therapist or client may end the session at any time for any reason but clients may still be                charged for a full session depending on the circumstances.

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

     

    Client Agreement:

    I understand that licensed 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.

    It is my choice to receive therapeutic massage as a form of therapy.

    I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

    I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my massage therapist so they can make adjustments to their approach. 

    I have shared all pertinent medical information, and will update the massage therapist of any changes in my health status.

    I understand that my failure to do so may pose a threat to my health and physical well being and I hold harmless  this massage therapist from any liability whatsoever arising from failure on my part.

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

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