Client Intake & Consent

Client Intake Form All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel infringes on personal information you do not wish to disclose.

Full Name*

First NameMiddle NameLast Name

Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number*

This is my:*

E-mail*

Emergency Contact*

Phone Number*

Occupation

Medications

Allergies

Prenatal Intake and Health History

1. In what week of pregnancy are you?*

2. What discomforts, pain, or other needs are you hoping to have addressed with massage therapy?*

3. Are you regularly seeing a physician, nurse-midwife, or midwide? Please provide name and phone number.*

4. Is your preganancy considered to be high risk (due to diabetes, hypertension, multiple pregnancy, previous complicated pregnancy, asthma, Rh or genetic problems, age under 20 or over 35 years of ages, fetal genetic disorders, or exposure to hazardous materials)?

5. List Areas of Discomfort or Pain*

6. Have you ever been in an accident (automobile, work, falls, etc.) ?*

7. Please list exercise and stress reduction activities (including frequency).*

Massage Policies: Client services and chart information are confidential. Written authorization is required from you to release any informaiton. • Please turn off your cell phone for optimal relaxation • Your scheduled session is set aside for you. We do not double book appointments. • 24 hour cancellation notice is required to avoid being charged for your session • Please reschedule your session if you are more than 15 minutes late • You will be draped and at no time will genitalia or breast tissue be exposed • You will have a consultation with your therapist to discuss your session • Should the session require, after your therapist has left the room, you may disrobe to your comfort level • I understand that my therapeutic 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 therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization. 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 therapeutic 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 also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic 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*

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