Health History Form

Health History Form

Please answer the following questions to help us provide safe and effective treatment. Your information will be kept confidential. Feel free to share any current concerns. Thank you.
PLEASE READ:
Filling out this form does not book an appointment, add you to the waitlist, or count as a form of communication.

To book, please visit the Booking tab on our website.
Contact Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reason for initial visit
How would you rate your overall health?
Have you had a professional massage before?

YesNo
How did you hear about us? If referred please let us know by who.
List any major accidents or surgeries( include dates, year is fine)
List all current medications & the conditions they are treating. If none put N/A*
If none put n/a

Informed Consent and Appointment Policy
Client Waiver Form
Please take a moment to read and initial the following information:

I give my permission to receive massage therapy and bodywork. I understand that therapeutic massage and bodywork are not substitutes for traditional medical treatments or medications.

I understand that my massage therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
I understand the importance of notifying my therapist of all known medical conditions, medications, and injuries and letting my therapist know about any changes to these. I understand that there shall be no liability on the therapist’s part should I forget to do so.

I understand that I am responsible for informing my therapist of any discomfort I may feel during the session so he/she may adjust accordingly. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

I understand that massage is entirely therapeutic & non-sexual. Our therapists WILL NOT tolerate inappropriate language, conduct, or sexual connotations. If behaviors are deemed inappropriate, the treatment will be ended & you will be responsible for full payment. We reserve the right to contact the authorities & the right to file a report and/or press charges if necessary.

I understand that the therapist or myself may end the session at any time for any reason.

I have read and understood the business no-show policy on the business's website and in the appointment confirmation email, text message reminders, and email reminders. As of January 1, 2022, if appointments are missed, a charge will be placed on your account, and it will need to be paid before receiving another service.
By signing this release, I waive and release my therapist from all liability relating to massage therapy and bodywork, past, present, and future.

By signing this release, I acknowledge and agree with the company's no-show policy, cancellation policy, and treatment etiquette policies.
Name*

First NameLast Name
Should be Empty:

Health History Form

Contact Information

Health History

Informed Consent and Appointment Policy