Journey ANu Massage Intake Form

Journey ANu Massage Intake Form

Name*

First NameLast Name

Date of Birth*

Address*

Address

Street Address Line 2

CityState

Zip

Phone*

Email*

example@example.com

Emergency Contact Name

Emergency Contact Phone

Referred by

Is this your first professional table massage?

What is your primary goal for today's service?

What is your occupation/ daily activities?

Are you seeing a Chiropractor or Physical Therapist?

What are your main areas of focus?

Any areas to avoid? (ie. scalp, face, stomach, feet, recent injury)

Do you have ANY of the following conditions?

List of current medications

Consent & Waiver

I have read, understand, and accept Journey ANu policies. I understand that Massage therapy and bodywork service are for professional health purposes and in a nonsexual environment. Sexual impropriety will not be tolerated. I understand that payment is due at the time of service or before. That a 24-hour cancellation or rescheduling notice is required. If I experience any discomfort during the session, I will immediately inform the therapist so the pressure can be adjusted to my comfort level. I understand that the services offered are not a substitute for medical care. Because massage therapy should not be performed under certain medical conditions, I agree that I have notified my therapist of all known medical conditions and injuries. I also agree to inform the therapist of any changes in my health and medical conditions. I understand that there shall be no liability on the therapist's part should I forget to do so. Any information provided is for educational purposes only and not diagnostically prescriptive in nature. By signing this release, I hereby consent to massage therapy and bodywork services, waive and release Journey ANu and its licensed massage therapist from any and all liability, past, present, and future relating massage and bodywork therapy services received from Journey ANu.

Name (Signature)*

First NameLast Name

Signature*

Date*

Date