Coronavirus Intake form for Massage Therapists

Name *

First Name Last Name

Email *

example@example.com

Phone Number *

Area Code Phone Number

What are your treatment goals for today?

Relaxation Injury Treatment Decrease Pain Increase Flexibility or Range of Motion

What is the location of pain and/or area's you would like treated?

What describes your pain/discomfort today (select all that apply)

Pain Numbness Tingling Throbbing Sharp Dull Soreness Tender to Touch Shooting

Intensity of Pain

Pain Scale 0-10, 0 is no pain 10 is the worst pain ever

Frequency

How often are you feeling this pain/discomfort

Was this pain a result of a car accident or injury related to your treatment?

Yes No

If Yes Date of Injury

Date

Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please turn off your cell phone for optimal relaxation

• Your scheduled session is set aside for you. We do not double book appointments

• Please reschedule your session if you are more than 15 minutes late

• 24 hour cancellation notice is required to avoid the charge of the full price of your session

• 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 and client will be responsible for payment of full session.

Client Agreement:

I understand that 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 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 undersand that at any time I feel pain or discomfort during the session, I will immediately inform my 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 Flawless Spa Retreat of Distinction and my massage therapists 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

Clear

Date

Massage Client Intake Form

For Office Use Only