• Massage Intake Form

    All information is held confident. At no given point is information disclosed or shared without client’s written consent. 
    Massage Intake Form
  • Date
     - -
  • Format: 0000 000 000.
  • Format: (000) 000-0000.

  • Services

  • Type of treatment*
  • Circle area of concerns

  • Health Information

  • Medications
  • Allergies
  • 4. Frequency
  • 5. At what time of day is the pain at its worse?
  • Please describe your emotional well-being:
  • What are your bowel movements like? (Our bowels play a big role in how we feel. This information can help me understand if visceral structures (organs) may be the source of your symptoms (low back pain/tightness, hip pain/tightness, shoulder pain/tightness etc)
  • Please check any of the following that apply to you now or past:

  • Oncology Treatment

  • Oncology - Pressure-related consideration

  • Fatigue
  • Easy bruising (low platelets)
  • Neuropathy: fingers, hands and or feet
  • Lymph node removal: Axilla, Neck, Groin, Abdo, Popliteal Fossa
  • Oedema or Lymphoedema
  • Bone density loss
  • Central line in situ

  • Client information are confidential and written authorization is required to release any information.

    We do not double book appointments

    Please reschedule session if more than 15 minutes late

    24 hour cancellation notice is required 

    You will have a consultation with your therapist to discuss the session

    You 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 therapy does not diagnose and heal illness, disease, any physical or mental disorder.

    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.

    I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction.

    I understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist. 

    I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

    By my electronic signature below, I agree to the massage policy and client agreement above. 

  • Should be Empty: