Autumn Dryden Massage Therapy
Intake & Consent to Treat
Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about me? If there's a person I can thank for referring you, please give me their name.
Health Data
How do you spend the majority of your day? Sitting at a computer, walking, driving, etc
If yes, please specify on the field above.
What brings you in for a massage today? If you're in pain, where and for how long has it been going on?
If yes, please specify on the field above.
Do you have any current injuries, recent surgeries, allergies, or health conditions I should know about?
If yes, please specify on the field above.
Consent and Waiver
I hereby consent for my therapist to treat me with massage therapy after assessment, examination, and explanation of techniques recommended. I acknowledge the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand massage is not a substitute for a medical examination. I understand there are other options I may seek if massage doesn’t solve my needs. I understand no assurances or guarantees have been made to me as to the results of this treatment. I understand that as with any treatment there may be risks. Any risks have been explained to me. I assume responsibility for those risks. I understand that the massage therapist must be fully aware of any existing medical conditions. I have completed my health intake form accurately. I also agree to keep the therapist apprised of any new conditions. I have been given time to ask questions about massage treatment.
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Submit
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