Massage Consent Form

Massage Intake Form

Please complete the questions and sign at the bottom.
Full Name*

First NameLast Name
Birth Date *

MonthDayYear
Date
Your address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail
Annotate Image by drawing or typing in the areas you feel pain so your massage therapist will know how to customize your massage session. At no time will the genitals, breasts, or midline of the gluteus be massaged nor should any client touch themselves in those areas while in the presence of the massage therapist.

Rate your pain on a scale of 1 to 10, with 1 being the least pain ever felt by you and 10 being the most amount of pain

	1	2	3	4	5	6	7	8	9	10

1 is Least , 10 is Most

(Optional) What areas of your body do you want massage to be FOCUSED?

upper body, neck, shoulders, arms, hands, scalp, and facelower body, glutes, hips, legs, knees, ankles, and feethands and feetlower backglutes, hips, and lower backcalves, hamstrings, quads, and glutesscalp, face, neck, and shouldersOther
Please select the following health conditions you have

High or Low Blood PressureDiabetesKidney diseaseCancerSpinal injuriesamputated limbmissing organ (i.e. left lung, kidney)recent abdominal surgery (post natal, tummy tuck, hysterectomy, etc.)Rheumatoid ArthritisOsteoporosisLeukemiaUse Blood ThinnersMigrainesRecent Surgeries (limbs, neck, low back, shoulders, etc.)Skin AbrasionsBruise easilyPlantar FasciitisFibromyalgiaTicklish feet or other areas of bodyCold hands and feetIrritable Bowel Syndrom (IBS)Other
(Optional) What are your massage goals? In other words, what do you expect to accomplish during your massage session?

increased range of motionrelaxed state of mindless to no pain in areas of my body that acheless fluid build up in areas of my body that have edemaless pain related to fibromyalgialess inflammation from stress
How did you hear about us?
Please read and sign below.

1. ACKNOWLEDGMENT OF RISKS

I understand that clinical massage therapy involves manual manipulation of soft tissues (muscles, tendons, ligaments, fascia) and may include techniques such as deep tissue, myofascial release, trigger point therapy, and stretching. While generally safe, I acknowledge that potential risks may include, but are not limited to: Temporary soreness, bruising, or discomfort Exacerbation of existing injuries or conditions Rare allergic reactions to oils or lotions Unforeseen complications due to undiagnosed medical conditions

2. INFORMED CONSENT I confirm that I have disclosed all relevant medical conditions, injuries, surgeries, allergies, and medications to my therapist. I understand that failure to do so may increase risks. I consent to receive treatment with the understanding that: Massage therapy is not a substitute for medical diagnosis or treatment. The therapist may modify or discontinue treatment based on my feedback or their professional judgment.

3. RELEASE OF LIABILITY I, the undersigned, voluntarily assume all risks associated with this treatment and hereby release Adam Bohach/Leverage LLC, from any liability for injuries, damages, or losses sustained during or resulting from the session, except in cases of gross negligence or willful misconduct.

4. CONFIDENTIALITY & RECORDS I consent to the collection of my health information for treatment purposes and understand that records will be kept confidential unless required by law or with my written permission.

5. CANCELLATION & POLICIES I agree to abide by the therapist’s cancellation policy (e.g., 24-hour notice for rescheduling/cancellations).
Please Sign and Date this form confirming you agree to the above statements.*

Powered by Jotform SignClear
Date (MM/DD/YY)*

MonthDayYear
Date
Should be Empty:

Massage Intake Form