Finger Lakes Massage Therapy Client Intake

Client Intake Form All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.

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*

E-mail*

How did you here about me?

Emergency Contact*

Phone Number*

Occupation

Are you experienced Fever - temperature of 100 degrees Fahrenheit or higher, Shortness of breath, Loss of sense of taste or smell, Dry cough, Runny Nose, or Sore throat in the past 14 days?*

NoYes

Have you been in contact with anyone who has COVID-19 in the past 14 days?*

NoYes

Medications That could affect session

Allergies

1. List Areas of Discomfort or Pain

2. Describe Onset of Discomfort or Pain

3. Rate of Pain Today

4. Frequency - please select the most accurate

5. At what time of day is the pain at its worse?

6. Have you ever injured this area before?

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

8. List all related treatments received for this injury.

9. Have you ever received therapeutic massage for a specific problem or injury?

Was the treatment used effective?

10. Is there anything that you do that creates, increases or decreases pain?

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

15. Are you currently seeing any other healthcare professional?

Policies

If I am not able to make a scheduled appointment, I agree to cancel or reschedule the appointment at least 24 hours in advance. I agree to pay for the full session rate with a card on file if I give less than 24 hours’ notice.Initial*

I understand I must arrive on time for my appointment in order to get the full session time I have scheduled. If I arrive late, I understand the therapist can only give me whatever time remains of my appointment, and that I will pay for the full length of the session that I booked.
initial*

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. initial *

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. I have notified my therapist of all known medical conditions and injuries and I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. Initial*

I understand that massage is entirely therapeutic and non-sexual in nature. I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19.

I hold harmless Finger Lakes Massage Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.initial *

Signature*

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