Massage Client Intake and Consent Form

Today's Date*

Date

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Occupation*

How did you hear about Reflexions?*

Facebook/InstagramOnline SearchReferralOther

If referred, by who?

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Area CodePhone Number

Are you currently under the care of a physician?*

YesNo

If yes, provide name and contact number.

Any recent surgeries?*

YesNo

If yes, please explain:

Do you have or have ever had any of the following?*

If other, please explain:

Any known allergies (check all that apply)?*

Please list any other allergies or sensitivities:

List any medications, supplements, or herbal remedies you currently take (enter n/a if none):*

Do you suffer from sinus problems?*

YesNo

Are you pregnant or breastfeeding?

YesNo

Have you had a Massage before?*

YesNo

If yes, when was your last massage?

Date

What daily activities/exercise do you undertake? *

Reasoning for session: *

Areas of focus (check all that apply):

By SUBMITTING AND SIGNING THIS FORM, I acknowledge, consent and agree to the following:

I give my permission to receive Massage & Bodywork services.

I understand that the therapist does not diagnose illnesses or injuries, or prescribe medications.

I understand that bodywork therapy may produce side effetcs such as muscle soreness, fatigue or sleepiness, headaches, and other possible temporary outcomes.

I acknowledge that this treatment is strictly professional and no inappropriate behaviors will be tolerated.

I understand that it is my responsibility to inform my therapist of any discomfort I may feel during the session so she may adjust accordingly.

I understand that I or the therapist may terminate the session at any
time.

I have been given a chance to ask questions about the session
and my questions have been answered.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.

Signature*

Reflexions

Medical History

Female Clients Only:

Session Information