• Massage Intake Form

  • Personal Information

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  • Medical Information

  • I understand the licensed therapist shall drape the breasts of all female clients and not engage in breast massage of female clients unless the client gives written consent before each session involving breast massage.

    Draping of the genital area and gluteal cleavage will be used at all times during the session for all clients.

    The licensed therapist must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature.

    If the client is uncomfortable for any reason, the client may ask the licensee to end the massage, and the licensee will end the session. The licensee also has a right to end the session if uncomfortable for any reason.

  • By signing below, you agree to the following. I have completed this
    form to the best of my ability and knowledge and agree to inform
    my therapist if any of the above information changes at any time.

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  • Client Release

  • I, * have read and understand the aforementioned conditions which make hot stone massage contraindicated. The massage therapist/practitioner has discussed this information with me and provided an opportunity for any questions. I have disclosed any and all health risk factors

  • is/are listed above and therefore make(s) hot stone massage contraindicated. Given this knowledge I hereby give my full consent to receive hot stone massage and take full responsibility of any side effects or harm that may come from my receiving hot stone massage.

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  • General Liability Release Form

  • By signing below, you agree to the following:

    1. I give my permission to receive massage therapy. 

    2. I understand that therapeutic massage is not a substitute for traditional medical 
 treatment or medications.
    3. I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications. 

    4. I have clearance from my physician to receive massage therapy.
    5. I understand the risks associated with massage therapy include, but are not 
 limited to:
      • Superficial bruising 

      • Short-term muscle soreness 

      • Exacerbation of undiscovered injury
 I therefore release the company and the individual massage therapist from all liability concerning these injuries that may occur during the massage session.
    6. I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition. 

    7. I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly.
    8. I understand that I or the massage therapist may terminate the session at any time. 

    9. I have been given a chance to ask questions about the massage therapy session and my questions have been answered. 

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