Therapeutic Massage Intake Form

Therapeutic Massage Intake Form

Please fill this form out prior to your massage appointment.
Date of Appointment

MonthDayYear
Date
How did you hear about FL Massage?
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any medications you are taking:
Please list any allergies/sensitivities:
Are you pregnant? If yes, how many weeks will you be, on the date of your appt?
Are you currently under medical supervision or receiving other medical intervention? If yes. Please give detail below:
Please list any areas of broken or compromised skin below:
Any history of joint replacement? If so, please list below:

Check all that apply

	Check if applicable
Areas of swelling
Autoimmune Disorder
Back/Neck Pain
Asthma
Arthritis
Eczema
Diabetes
Cancer
Carpal Tunnel
Vericose Veins
Hypertension

	Check if applicable
Heart Disease
Anemia
Digestive Disorder
Covid
Migraines
Sciatic
Ulcer
Epilepsy
Stroke
TMJ
Neuropathy

Recent injuries or medical procedures in the past 2 years? Please describe
Have you had a professional massage before? How recently?
Type of massage you're seeking?

RelaxationTherapeutic/Deep Tissue/Trigger point therapy
Areas you do NOT want massaged?

FaceFeetAbdomenGlutesScalp
How much pressure do you usually prefer?

LightMedium?Firm
Massage Therapy Consent and Release From

I voluntarily request and consent to receiving massage therapy.

I understand that the massage service offered is for the purpose of general wellness, stress reduction, and relief of muscular tension only.

I do not have any injuries or conditions that prevent me from receiving massage therapy. I understand the importance of informing my massage therapist of all medical conditions and medications that I am taking,
and that there may be additional risks based on my physical condition.

If I experience any pain or discomfort, I will immediately inform my therapist so that the pressure or techniques used can be adjusted to my comfort level. I will not hold my massage therapist responsible for any pain or discomfort I experience during or after the session.

I understand the risks associated with massage therapy include, but are not limited to:
Superficial bruising
Short-term muscle soreness
Exacerbation of undiscovered injury

I have not received a positive test for coronavirus within the past 14 days, and currently have no symptoms.

I do not have any contagious conditions that may put my massage therapist or other clients at risk.

I understand that I or the massage therapist may terminate the session at any time.

I have been given the opportunity to ask questions about massage therapy and my questions have been answered.
I have been advised of the policies and procedures pertaining to massage and I understand these policies. Information regarding massage in general, benefits, contraindications of massage, and possible alternative therapies have been explained to me. I further understand that massage therapy is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness or disease, and nothing said during the massage should be construed as such. My consent is informed and
voluntary and I understand that I may withdraw my consent at any time except for actions already taken.
Client Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: