Massage Therapy Intake Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Emergency Contact Information
Name, Relation & Phone Number
Occupation
Does your job require you to sit, stand, or walk for long periods of time? Please explain below.
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Have you ever received a professional massage before?
Yes
No
If yes, when was your last massage?
What type of pressure do you prefer?
Light pressure
Medium pressure
Deep pressure
I’m not sure
Describe your goals of massage therapy
(i.e stress relief, pain relief, specific problem, general relaxation/wellness)
Please list any areas you do NOT want massaged due to injury, sensitivity or just your personal preference?
Do you exercise? If yes, please list type of exercise and frequency.
Please list any medications you are currently taking and the conditions they are treating
Do you have any allergies? (i.e oils, lotions, etc.) Please list below
Are you currently pregnant or breastfeeding? If pregnant, please list your due date.
Please list any major accidents, injuries or surgeries below.
Select all that apply
Please list any other health conditions below.
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Photo Consent
As part of our promotional efforts, we sometimes take photo/video of our clients treatment to share on social media. By selecting "yes" below, you agree to the terms outlined in this consent. I understand that these photos/videos may be used in promotional materials, advertisements, and other platforms for promotional purposes. I understand that my participation is voluntary and I have the right to decline or withdraw consent at anytime - verbally or in writing.
Do you consent to photo/video documentation?
Yes
No
Informed Consent
The above information is accurate to the best of my knowledge and I freely give my permission to be massaged. I agree to inform my massage therapist of any health or medical changes. I agree to inform my massage therapist of any experience of pain during the session so that the pressure or techniques can be adjusted to my comfort level. I understand the risks of massage therapy include but are not limited to: superficial bruising, short-term muscle soreness, or exacerbation of undiscovered injury. I understand that the massage therapy I am receiving is for the purpose of stress reduction, general relaxation, relief from muscular tension or spasm, and/or improving circulation. I understand that a massage therapist does not diagnose illness, disease, or any other medical, physical or mental disorders; nor performs spinal manipulations. I am responsible for consulting a qualified physician for any physical ailment I may have.
Draping Policy
Clients will be appropriately draped with a sheet and/or towel at all times during the massage session. Only areas of the body that are currently being treated will be exposed. The breast and genital areas will always remain draped and never massaged.
Massage Termination Policy
Only professional massage and bodywork services for relaxation or therapeutic purposes are offered at this massage practice. Massage services will be terminated immediately in the event of inappropriate conduct of any kind. This includes harassment, threatening speech or behavior, sexual advances or requests, exposing oneself, or disrespectful actions/language. If the client appears to be under the influence of drugs or alcohol, the session will be terminated. If the massage is terminated for any of these reasons, full payment of the scheduled session is still required, no refunds will be issued and the client will be indefinitely banned from booking future services.
Cancellation and No-Show Policy
We require 24 hour notice to cancel an appointment. Clients who cancel an appointment with less than 24 hour notice may be billed 50% of the scheduled service. Clients who do not show up to a scheduled appointment will be billed 85% of the service and are subject to a permanent booking ban.
Late Arrival Policy
Clients who arrive late to their appointment will be charged for the full session and will not receive a time extension. Clients who are 15 minutes or more late will be considered a no-show and the card on file will be charged according to our no-show policy.
By signing this form you agree to policies above.
Date
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Month
-
Day
Year
Date
Signature
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