Honest Energy Massage
Therapeutic Massage Intake Form
Client Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Health Data
Have you ever received a massage before? If yes, please elaborate:
*
If yes, please specify on the field above.
What type of pressure do you prefer? (light, medium, firm, deep, mix of any, etc.)
Please list any current medications
*
If yes, please specify on the field above.
Do you have any allergies?
*
If yes, please specify on the field above.
Type a question
Are you pregnant or nursing?
*
If yes, please specify on the field above.
What is your goal for the session? (relaxation, stress relief, pain relief, etc.)
*
Do you have any current injuries or ailments?
*
If yes, please specify on the field above.
Please list any surgeries or major injuries you have had in your lifetime here:
*
If yes, please specify on the field above.
Current medical conditions like Osteoporosis, Diabetes, Heart conditions, Kidney conditions, epilepsy, scoliosis, communicable disease, etc.
*
If yes, please specify on the field above.
How did you hear of us?
Consent and Waiver
Please review and accept:
*
I authorize Honest Energy to perform the treatment necessary in their office, or another location agreed upon by all parties.
I acknowledge that I am responsible for 50% of the session price if the cancellation is within 24 hours of my appointment, and 100% of the session price if I am late or do not show up. My appointment begins at our scheduled time regardless of if I am late or not. If I am more than 15 minutes late to my appointment I understand that it may be cancelled, and I will be charged 100% of the session price.
I understand that massage therapy is for the purpose of stress reduction, relief from muscular discomfort and for increasing blood, lymph, and energy circulation. I further understand the massage therapist does not diagnose illness, disease, or any other physical disorder. As such, the massage therapist does not prescribe medical treatment, medication(s), and does not perform spinal manipulation. By signing below, I further agree that I will not hold the massage therapist or its affiliates responsible should there be any unfavorable outcome or result.
I acknowledge that I am receiving a therapeutic massage. Any inappropriate sexual behavior will terminate the session, and I will be liable for payment of the scheduled treatment.
I acknowledge that I have filled out this waiver to the best of my knowledge, and stated all known medical conditions.
Please review and accept only if applicable:
I consent to the use of any photos or videos taken during my session to be used for marketing. These photos may appear on Honest Energy's website and/or social media.
By signing below, I acknowledge that I have fully read and completely understand the above statements, and that I have answered every section truthfully.
*
Date Signed
*
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Month
-
Day
Year
Date
Submit
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