Massage Therapy Intake Form
By Sport Affiliated Massage Therapy
Personal Information
Name
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First Name
Last Name
Gender
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Female
Male
Non- binary
Age
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Phone Number
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Email Address
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example@example.com
Home Address
Street Address
City
State
Zip Code
Preferred Contact Method:
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Text
Call
Email
How long would you like your massage session to be?
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60 minutes ($129.99)
90 minutes ($159.99)
120 minutes ($199.99)
Which massage service(s) would you like to include in your session?
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Swedish Massage (Relaxing, gentle massage for stress relief.)
Deep Tissue (Targets deep muscle tension and stiffness.)
Sports Massage (Boosts flexibility, reduces spasms, and speeds recovery.)
Cupping Therapy (Uses suction cups to relieve muscle pain and improve circulation.)
Hot Stone Massage (Warm stones soothe and relax tight muscles.)
Stretch & Joint Mobilization (Restores joint mobility and relieves stiffness.)
Sciatic Treatment - (Focused work on sciatic nerve relief using multiple techniques.)
Based on my lifestyle, I consider myself a(n):
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Couch Potato — I mostly relax with passive activities like TV or browsing the internet.
Occasional Mover — I move here and there, by walking or engaging in light activity, but don’t exercise consistently.
On-the-Go — I stay active throughout the day due to work or daily activities, but I don’t exercise regularly.
Weekend Warrior — I am inactive during the week, but exercise or play sports on the weekends.
Fitness Enthusiast — I work out 3-5 times a week and stay fit by going to the gym or running.
Athlete - I train intensely, usually daily, and compete in sports or high-performance activities.
Which service are you interested in? (Please select all that apply)
Deep Tissue Massage
Sports Massage
Myofascial Release
Stretching & Mobility Sessions
Chair Massage for a work party event
Other services (e.g., Cupping, Muscle Scraping/Gua Sha
Where are you feeling pain or discomfort? (Please select all that apply)
Neck
Shoulders
Upper Back
Lower Back
Arms
Hands/Wrists
Hips
Legs
Feet/Ankles
Everywhere - I’m basically a human know
Other
Please specify why you are inquiring about a massage: (e.g.: Stress relief, pain management, injury recovery, improving mobility, relaxation, maintenance, etc.)
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Do you have any skin allergies or intolerances? If yes, list below
Massage & Stretch Therapy Client Agreement Our Terms and Conditions
KneticRx Athletic Club & Affiliated Providers This agreement (“Agreement”) is entered into by and between the undersigned client (“Client”) and KneticRx Athletic Club, including its partnered and affiliated service providers (“Provider”), and shall govern the terms and conditions of all massage and/or stretch therapy services (“Services”) rendered by the Provider. By signing below, the Client acknowledges, understands, and agrees to the following: 1. Medical Disclosure and Risk Acknowledgment Client affirms that they have disclosed all known medical conditions, injuries, and current medications that may affect the outcome or safety of the Services. Client understands that massage and/or stretch therapy is not a substitute for medical examination, diagnosis, or treatment, and that they should consult a licensed medical professional for any medical concerns. Client acknowledges and accepts the inherent physical risks associated with massage and/or stretch therapy, including but not limited to muscle soreness, fatigue, or other temporary discomforts. Client hereby releases and holds harmless KneticRx Athletic Club and its Providers from any liability resulting from such outcomes, unless arising from gross negligence or willful misconduct.2. Appointment Booking and Attendance All appointments must be scheduled in advance. A minimum of twenty-four (24) hours' notice is required for cancellation or rescheduling of any appointment. Cancellations made with less than twenty-four (24) hours' notice, or failure to attend a scheduled appointment (“No-Show”), may result in the Client being charged the full session fee at the Provider’s discretion. Late arrivals may result in the session being shortened accordingly, with no reduction in the session fee. The full fee remains due and payable regardless of the adjusted session duration. 3. Payment Terms and Refund Policy Payment for all Services is due at the time of booking unless otherwise agreed in writing. The Client understands and agrees that refunds are not available once the session has been rendered. Dissatisfaction with outcomes shall not constitute grounds for a refund. However, Client feedback is welcomed and will be considered to improve future service quality.4. Client Conduct Client agrees to behave in a professional, respectful, and lawful manner throughout the duration of all interactions with the Provider and any staff affiliated with KneticRx Athletic Club. Any inappropriate, offensive, or unsafe behavior, as determined in the sole discretion of the Provider, shall result in immediate termination of the session and permanent disqualification from future services. In such cases, no refunds will be provided.5. Provider Rights Provider reserves the right to refuse service or terminate any session if it is determined that continuing the service would be unsafe, unprofessional, or in violation of any legal, medical, or ethical standards.6. Confidentiality All client information, including intake forms, health disclosures, and session records, shall be maintained in strict confidentiality and will not be disclosed to any third party unless required by law or with the client’s written consent. Records may be securely stored and accessed by authorized personnel within KneticRx Athletic Club to ensure continuity of care.7. Policy Revisions KneticRx Athletic Club and its Providers reserve the right to revise these terms and conditions at any time. Clients will be notified of any material changes that affect the nature of services, privacy, or payment policies.8. Acknowledgment and Consent By signing below, the Client confirms that they have read, understood, and voluntarily agree to abide by the terms of this Agreement. The Client further acknowledges that they have had the opportunity to ask questions and receive clarification before signing.
Client Acknowledgment
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I have read and agree to the terms outlined in this agreement.
Signature
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Submit
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