Massage Consent Form

Massage Intake Form
Personal Information
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Emergency Contact Information
Name of Emergency Contact
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
DOB

MonthDayYear
Date
Occupation
Primary Physician
How did you hear about us?
Medical Information
Are you taking any medications?

YesNo
If yes, please list name and use:
Are you currently pregnant?

YesNo
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain?

YesNo
If yes, please explain:
What makes it feel better?
What makes it worse?
Have you had any orthopedic injuries?

YesNo
If yes, please list:
Please indicate any of the following that apply to you:

CancerFibromyalgiaHeadaches / MigrainesStrokeArthritisHeart AttackDiabetesKidney DysfunctionJoint Replacement(s)Blood ClotsHigh / Low Blood PressureNumbnessNeuropathySprains or Strains
Please explain any conditions you have marked above:
Massage Information
Have you had a professional massage before?

YesNo
What type of massage are you seeking?

RelaxationTherapeutic / Deep TissueOther
What pressure do you prefer?

LightMediumDeep
Do you have any allergies or sensitivities?

YesNo
If yes, please explain:
Are there any areas (feet, abdomen, etc.) you do not want massaged?

YesNo
Please explain:
What are your goals for this treatment session?
Is there anything you would like us to know about you before receiving your service?
By signing below, you agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that. I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.
Client Signature
Date

MonthDayYear
Date
Therapist Signature
Date

MonthDayYear
Date
Should be Empty:

Massage Intake Form

Personal Information

Medical Information

Massage Information