Intake

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Name

First Name

Last Name

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Date of Birth

Date

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Any relevant injury, illness, or surgery?

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Any allergies?

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Any medications?

6

Liability WaiverI understand that the massage service offered is for the therapeutic purpose of general wellness, stress reduction, and relief of muscular tension. Information about massage therapy, potential benefits, effects, risks, contraindications, and possible alternative therapies have been explained to me and I understand this information. I understand the risks associated with massage therapy include, but are not limited to: superficial bruising, short-term muscle soreness, and/or exacerbation of undiscovered injury. I have been given the opportunity to ask questions about massage therapy and my questions have been answered to my satisfaction. If I experience any pain or discomfort, I will immediately inform my therapist so that the pressure or techniques can be adjusted to my comfort level. I will not hold my massage therapist responsible for any pain or discomfort I experience during or after the session. I have provided my therapist with an accurate and complete medical history and agree to inform my therapist of any new diagnoses, or changes in my health or medications. I do not have any injuries or conditions that prevent me from receiving massage therapy. I understand the importance of informing my massage therapist of all medical conditions and medications that I am taking, and that there may be additional risks based on my physical condition. I understand that I or the massage therapist may terminate the session at any time. I release the massage therapist and business from all liability for any harm that may unintentionally result from this treatment. I further understand that massage therapy is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness or disease, and nothing said during the treatment should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken. By signing this form I agree to the conditions as outlined above, and I release the massage therapist and business from all liability for any harm that may unintentionally result from this treatment.

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