SPHC Massage Intake

Massage Intake

Please Complete All Fields
** Items Necessary For Your Visit **

- Current Valid Photo ID

- Facial Mask Required To Be Worn Throughout Entire Appointment
Name*

First NameLast Name
Date of Birth*
XX/XX/XXXX
Email Address*
example@example.com
Mobile Phone
XXX-XXX-XXXX
Home Phone*
XXX-XXX-XXXX
Work Phone
XXX-XXX-XXXX
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Emergency Contact Name*
Emergency Contact Phone
Emergency Contact Address
Next of Kin Name*
Next of Kin Phone
Next of Kin Address
Briefly Describe What Brings You In Today?*

Consent & Liability
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 or 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.
By signing below, you agree to the following:

1. I give my permission to receive massage therapy.

2. I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.

3. I understand that the massage therapist does not diagnose illnesses or injuries, or perscribe medications.

4. I have clearence from my physician to receive massage therapy.

5. I understand the risks associated with massage therapy include, but are not limited to:
- Superficial brusing
- Short-term muscle soreness
- Exacerbation of undiscovered injury
I therefore release the company and the individual massage therpist from all liability concerning thes injuries that may occur during the massage session.

6. I understand the importance of informing my massage therapist of all medical conditions and medications that I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition.

7. I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly.

8. I understand that I or the massage therapist may terminate the session at any time.

9. I have been given a chance to ask questions about the massage therapy session and my questions have been answered.
Name*

First NameLast Name
Date*
XX/XX/XXXX
Signature*

Clear
Should be Empty:

Massage Intake

Medical Conditions

Consent & Liability