Massage Therapy Client Intake

Sports Massage Client Intake Form

All information is held with strictest confidence. At no given point will the information provided be shared without the clients written consent.

Name

Date

MonthDayYear

Address

Street Address

Street Address Line 2

City

Post CodeCountry

Birth Date

MonthDayYear

Phone Number

E-mail

Emergency Contact

Their phone Number

Phone Number

Preferred Clinic - please select

Medications

Allergies

Do you currently have or have you previously had any of the following conditions? (If applicable please select more than one option)

History of Injury

Is there a specific area that is tight?

Please list the areas of discomfort or pain

Please list the days and time frames that work best for you.

Please select the Appointment you require.

Do you give permission to contact you on the number you have given to arrange an appointment?

Please note an appointment will not be confirmed until half of the payment has been received as deposit.

Massage Policies:

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

• A deposit of half of the full amount will be taken when the Massage therpaist confirms your appoitment.

• 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. If you fail to show or cancel within 24 hours then the deposit will be non refundable.

• I understand that my 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:

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

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 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 understand that some bruising may occur.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my 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 hold harmless Pure Touch 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.

Signature (Parent signature)

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.