Body & Head Massage Intake & Consent Form

Body & Head Massage Intake & Consent Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact*

NamePhone Number
Medical History & Health Screening
Please check all that apply:*

Heart conditions or high blood pressureRecent surgery or injuriesSkin conditions (eczema, psoriasis, rashes)Chronic pain or musculoskeletal disordersCirculatory issues (varicose veins, blood clots)Neurological conditions (e.g., seizures, stroke)Respiratory conditions (e.g., asthma)PregnancyAllergies to oils, lotions, or essential oilsCancer or recent chemotherapy/radiationInfectious diseasesNone of the AboveOther
Treatment Information

Massage therapy involves manual manipulation of muscles and soft tissues to promote relaxation, relieve pain, and improve circulation. Head massage focuses on the scalp, neck, and shoulders to reduce tension and improve relaxation.
Possible Risks & Side Effects

I understand that massage therapy may include:
- Temporary soreness, redness, or bruising
- Muscle fatigue or mild discomfort
- Headache or lightheadedness (rare)
- Allergic reaction to oils or lotions
Contraindications

I understand that massage is not recommended if I have:
- Open wounds, burns, or skin infections in treatment area
- Recent fractures, surgery, or severe injury
- Blood clotting disorders or use of blood thinners
- Contagious skin or scalp conditions
- Severe heart or respiratory conditions (unless cleared by physician)
- Pregnancy (without notifying therapist)
Acknowledgement and Consent
I confirm that:*

I have disclosed all relevant medical history and medications.I understand that massage therapy is not a substitute for medical care.I understand potential risks and consent to receive massage therapy.I release the therapist from liability for adverse effects if I fail to follow pre- or post-care instructions.
Client Name*
Client Signature (If under 18 signature of parent or guardian)*
Date*

MonthDayYear
Should be Empty:

Body & Head Massage Intake & Consent Form

Medical History & Health Screening

Treatment Information

Possible Risks & Side Effects

Contraindications

Acknowledgement and Consent