Massage Therapy Client Intake

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent.

Full Name*

First NameLast Name

Phone Number*

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

What style of massage are you requesting?

deep tissue, sports , prenatal etc.

How long is your massage?

60min90min

How did you hear about us?

Have you ever had body work or a massage before?

Have you been here before?

Are you interested in our buy one get one monthly offer?

* 1 year required

Are you interested in bulk pricing?

Share them birthday, holidays, or giveaway. You get a booklet with coupons to cut out. Good for 12 months.

Please check if you have any of the following:

Are there any areas you don't want massaged?

Feet, face, abdomen etc.

1. List Areas of Discomfort or Pain*

Front

2. List areas of Discomfort or pain*

Back

Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please turn off your cell phone for optimal relaxation

• Your scheduled session is set aside for you. We do not double book appointments

• Please reschedule your session if you are more than 15 minutes late

• 24 hour cancellation notice is required to avoid being charged for your session

• You will be draped and at no time will genitalia or breast tissue be exposed

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

• Should the session require, after your therapist has left the room, you may disrobe to your comfort level

• I understand that my therapeutic massage therapist or I 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 therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

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.

It is my choice to receive therapeutic massage as a form of therapy.

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

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.

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

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Pure Touch Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

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

Date

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.