• MASSAGE INTAKE FORM

  • This information requested below will assist your therapist in providing safe, professional care. This form will be kept in confidence in accordance with HIPAA privacy requirements. Completion of this form is mandated by the Texas Department of State Health Services.

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  • PLEASE READ THE FOLLOWING INFORMATION CAREFULLY

    Massage is provided for the basic purposes of relaxation and relief of muscular tension. If you have a specific medical condition or specific symptoms, massage therapy may be contraindicated. Massage therapy is not a substitute for medical treatment. Massage therapists do not diagnose illness or prescribe medications. Nothing said in the course of your massage session should be construed as such. Massage therapists do not perform spinal manipulations or skeletal adjustments, nor do they treat any physical or mental illness or disease.

    Breast massage after augmentation, reduction or mastectomy has been shown to minimize scar tissue. Breast massage will not be performed unless

    these conditions exist and then, only with written consent. Breast massage requires temporary undraping of the breast area to visually inspect the tissue. If you agree to breast massage, please sign your consent below:

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  • I affirm that I have provided all information requested honestly and fully. If my reason for seeking massage, my medical history or any other consent I have provided changes, I will advise the therapist so that an updated consultation can be completed. I understand that the use of drugs and/or alcohol is contraindicated for massage therapy and I attest that I am not under the influence of drugs and/or alcohol now, nor will I ever be, for a massage session. I hereby give my consent to receive massage therapy today and in the future until I advise otherwise in writing. I also provide my consent to receive massage from other therapists at Chrysalis as noted on this form.

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  • The following information is provided pursuant to the Texas Department of State Health Services Massage Therapy Rules (25 Texas Administrative Code, Chapter 141 There should be no blank spaces on this form. If not applicable, enter "N/A" in the space provided.

  • If you experience any pain or discomfort during the session, you should immediately inform the therapist so that the pressure and/or strokes may be adjusted to your comfort level. If you desire, the session can be modified or terminated at any time.

    This massage practice requires that your body be covered (draped) at all times during the session, except for the area/s being massaged. Please do not remove the draping without the therapist's agreement. Any illicit or sexually suggestive remarks or advances made by the client, including removal of draping, will result in immediate termination of the session with the client owing for the entire session.

    Massage should not be performed when certain medical conditions exist. Please be sure that you have stated all of your known physical and medical conditions, including medications you currently take and that all of your answers are complete and correct.

    The following therapists, at the client's request, have reviewed this information and have been approved by the client to perform massage:

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  • Should you have a complaint about the services of a Licensed Massage Therapist, please contact the Texas Department of State Health Services Massage Therapy Licensing Program at 512-834-6616.

    Chrysalis 2615 Southwest Freeway, Suite 240 Houston, TX 77098 713-522-2111 spachrysalis.com

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