Client Intake Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date*

MonthDayYear

Email*

example@example.com

Cell Phone Number*

Please enter a valid phone number.

Have you ever had a professional massage?*

YesNo

Medical History (Select ALL that apply, past or present)

Please describe any medical conditions or previous surgeries below. (Type N/A if you have no medical conditions or surgical history)*

Type N/A if no conditions selected

Please list any over-the-counter supplements, prescription medications, and non-prescription medications you are currently taking and what they are used for. (Type N/A if not applicable)*

Are you currently wearing contact lenses?*

YesNo

Are you pregnant or breastfeeding?*

Yes, I'm pregnant.Yes, I'm breastfeeding.No/Not Applicable

Do you have any allergies?*

YesNo

If you have allergies, please list them here:

Are you currently wearing dentures?*

YesNo

Are you currently wearing hearing aids?*

YesNo

Are you currently under a physician's care?*

YesNo

If yes, please explain:

Physician's Name*

First NameLast Name

Physician's Phone Number*

Please enter a valid phone number.

Emergency Contact*

First NameLast Name

Emergency Contact's Phone Number*

Please enter a valid phone number.

Waiver

I, {name}, have completed this form to the best of my knowledge.

Consent for Treatment

I voluntarily consent to receive massage therapy and bodywork services provided by Elizabeth Rivera and MyoQi Athletics LLC. I understand that massage therapy is designed to be a health aide and not a substitute for medical care by a physician. I acknowledge that results may vary based on individual health conditions and needs.

Understanding of Services

I understand that massage therapy is designed to be a health aide and not a substitute for medical care by a physician.

I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, as well as improvement of circulation and energy flow.

If I experience pain or discomfort during the session, I will immediately inform my therapist so that the pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort that I experience during or after the session.

I understand that my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness.

I affirm that I have notified my therapist of all known medical conditions and injuries.

I agree to inform the therapist of any changes in my health and medical condition and that there shall be no liability on the therapist's part should I forget to do so.

I understand that massage is entirely therapeutic and non-sexual in nature.

Consent for Photography/Social Media Release

I consent to the taking of photographs or videos during my sessions for the purpose of documentation, treatment planning, and promotion. I understand that these images may be used for social media, marketing, and educational purposes. I acknowledge that I will not receive any compensation for the use of these images. If I do not consent to photography or social media usage, I will inform my therapist prior to the start of my session.

Privacy Policy

I hereby consent to MyoQi Athletics LLC possessing and utilizing my medical and personal information for the purpose of providing massage therapy services. All information provided will be kept confidential and will not be disclosed to third parties without my written consent, except as required by law.

By signing this release, I waive and release Elizabeth Rivera and MyoQi Athletics LLC, along with their representatives, from any and all claims and liability, past, present, and future, relating to massage therapy and bodywork.

Signature*

Massage Therapy Client Intake Form