Balance in Motion Massage Intake Form

Balance in Motion Massage Intake Form

All information is held confident. At no given point is information disclosed or shared without client’s written consent.
Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.

Client information are confidential and written authorization is required to release any information.

We do not double book appointments

Please reschedule session if more than 15 minutes late

24 hour cancellation notice is required

You will be draped and at no time be exposed

You will have a consultation with your therapist to discuss the session

You 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 therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder.

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.

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

I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

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