Client Intake Form - Massage Therapy

Client Intake Form - Massage Therapy
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact
(Name, Relationship, Phone Number)
Occupation
How did you hear about me?

Current Health
What is your intention for your session?
Do you have any areas of tension, discomfort, or pain? Please describe:
Please describe any recent injury, surgery, or areas of inflammation:
Please list any other accidents or surgeries you have had:
Medications/supplements you are currently taking and their purpose:
List any allergies, including oils, lotions, or ointments.
What makes your pain better? What makes your pain worse?
How would you describe a typical day or week in your life?
What is your average stress level on a scale from 1-10 and why?
What does self-care look like for you? (Consider physical, emotional, and spiritual)
How much water do you drink in an average day?
Have you ever had a professional massage? If yes, please list type and frequency.
What kind of pressure do you like?
Are their any areas you would like me to avoid?

Client Agreement
Purpose of Massage Therapy

I understand that massage therapy is intended to augment wellbeing, reduce pain, increase range of motion and offer a therapeutic experience of touch.

Massage Therapy and Medical Care

I understand that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I concurrently work with my Primary Care Provider for any condition I may have.

I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not part of massage therapy.

Disclosure of Medical Information

I have informed the massage therapist of all my known physical conditions, medical conditions, and medications, and I will keep the massage therapist updated on any changes. I understand that there shall be no liability on the practitioner’s part due to my forgetting to relay any pertinent information.

Risks and Liability

I understand the risks associated with massage therapy include, but are not limited to: superficial bruising, temporary inflammation of tissues, short-term muscle soreness, and exacerbation of undiscovered injury. I therefore release the massage therapist from all liability concerning these injuries that may occur during the massage session.

I understand and agree to abide by the therapist’s policies and will not hold the therapist responsible for any personal injury or loss of property.
Cancellation Policy
Deposit
To secure your massage booking, a deposit of $25 for 60-minute sessions or $37.50 for 90-minute sessions is required at the time of scheduling. This deposit will be applied to the cost of your session.

Cancellations/No-Shows
If you cancel less than 24 hours before your appointment or do not show up for your scheduled session, the deposit is non-refundable.

In addition, you will be charged 50% of the session fee, minus the deposit already paid, to cover the time reserved for you.

Extenuating Circumstances
I fully understand that life can be unpredictable, and emergencies may arise. If something unexpected happens, please reach out as soon as possible. I'll do my best to work with you and accommodate your situation in a respectful manner.
By signing below, I acknowledge that I have read and understand the Client Agreement and Cancellation Policy.
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Date*

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Client Intake Form - Massage Therapy

Current Health

Health History

Client Agreement

Cancellation Policy