Massage Therapy Intake Form

Name*

First NameLast Name

Email*

Phone Number*

Address*

Street Address

CityState / Province

Postal / Zip Code

Occupation

DOB *

Is this appointment/paperwork for a minor? If yes, parent/guardian input your information in Emergency Contact below*

YesNo

Emergency Contact Name & Number

Who referred you / How did you find me?*

(Google search, flyer from gym or work, referral)

If you are taking medications for pain management or cardiovascular disease control please list them here:

Painkillers/anti-inflammatories, ACE inhibitors, Beta or Calcium channel blockers, blood thinners etc

Any allergies? (oils, nuts, fruits, skin, etc)

Are you pregnant or nursing?

How many months / Due date / etc

Please list any 1) recent injuries 2) medical procedures in the past 2 years and 3) joint replacement(s) as well as any other pertinent medically related concerns:

Have you had professional massage before?

YesNo

If yes, when was your last massage?

Reason for seeking massage:*

Relaxation / Specific problem or pain - please be detailed in your response to ensure your session is customized to your specific wants and needs.

How much pressure do you prefer? You can select more than one; we will discuss preference(s) at time of session.*

LightMediumFirmDeep

By sumbitting this form you agree to the following:

Zero Tolerance Policy:

I understand this massage is for therapeutic purposes only, and any sexual remarks, jokes, and advances will be taken seriously. I will be fully draped during this session, and my therapist will only uncover the area being worked on. Failure to respect this policy will result in termination of my session, and I will be liable for full payment of the scheduled treatment.

I understand that my massage therapist is not qualified to perform spinal adjustments, diagnose, prescribe for, or treat any medical condition. If I have a specific medical condition, massage may be contraindicated and a letter of approval from my primary care physician may be necessary prior to treatment.

Confidentiality Agreement:

I understand that all of the information contained in this intake is confidential and will only be used by my massage therapist and the in office chiropractor, if applicable. My therapist will never share any of my information with anyone else.

Cancellation Policy:

I understand all changes or cancellations of an appointment that are not made within 24 hours of the appointment time, may be subject to a cancellation fee of the full appointment cost.

If the card I provided to hold my apointment is unable to be charged for the cancellation or no-call/no-show fee, an invoice will be added to my account, and I will be liable for the payment at my next appointment time.

After 3 cancellations/no-shows, I may not be allowed to schedule appointments without full payment in advance.

Treatment of a Minor:

If this appointment/paperwork is being completed for a minor, by signing below, you acknowledge that you are the parent/legal guardian of the mino who is to recieve massage or bodywork at this facility. You acknowledge that you have read and understand all information on this form and authorize this massage practice to provide therapeutic massage and bodywork for your child/dependent.

Final Statement:

I have completed this form truthfully, and to the best of my ability and knowledge, and agree that I understand the benefits and risks of massage and that I will inform my therapist if any of the above information changes at any time.

Signature

Date*