LSPR Massage Therapy Intake Form

LSPR Massage Therapy Intake Form
Thank you for choosing to receive a massage through Lee’s Summit Parks and Recreation! Please complete this form so your massage can be personalized to your current needs and preferences. During the massage, do not hesitate to give feedback about the depth of pressure, techniques, or draping to ensure a comfortable, effective session.

If you have had flu or cold symptoms in the last 48 hours, or have anything contagious, cuts, or open sores, your massage might not be performed. If you have cancer, a current high-risk pregnancy, or any other significant medical condition, please get written permission from your healthcare provider before your massage, including any restrictions on modality, length of the massage, depth of pressure, and any areas to avoid.

Clients under the age of 18 must have a parent or guardian complete this form in front of a staff member. Ages 14-17 must have a parent's consent and have a parent in the room at the time of the service. Ages 13 and younger are not permitted to receive a massage.

LSPR Massage Therapy Intake Form
Participant Name*

First NameLast Name
Date of Birth (MM/DD/YYYY)*

MonthDayYear
Clients under the age of 18 must have a parent or guardian complete intake form at the front desk.
Phone*

Area CodePhone Number
Email Address*
email@email.com
How did you hear about us? *
Please include name if you were referred
Reason(s) for getting a massage:*
Do you receive professional massage often or have you ever? *
Repetitive movements you perform daily at work, etc.:*
Exercise or movement hobbies you perform regularly:*

By signing this form, you agree to the following:

I understand that the message I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part if I should fail to do so. I understand that this is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.

I understand the benefits and risks of massage and give my consent for treatment. It is also understood that the massage therapist reserves the right to refuse service to anyone. I will consult with my massage therapist as to any questions or concerns immediately. I have stated all my known medical conditions and will inform my massage therapist of any changes. I understand that the purpose of this massage is to reduce stress and increase relaxation. I will immediately inform the massage therapist if I am uncomfortable with the pressure or stroke so it may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis or treatment and that I should consult a physician, chiropractor or other qualified medical specialist for any mental or physical ailment I am experiencing.
Signature of client*

Clear
Date*

MonthDayYear
Date
Should be Empty: