Akros Bodywork Client Intake Form Logo

  • Client Intake Form

    Prior to our session, please complete the health form below to the the best of your knowledge. All personal and health information is held strictest confidence. At no given point is your private information disclosed or shared with any person or entity without your prior written consent. 

  • Client Information

  •  - -

  • General Health Information

  •

  • Health History

    Provide information for the past 5 years including type, approximate dates and treatments. If none please indicate "None". Click "+" to add another item.

  • Health Conditions

    Please check all current and previous conditions (within past 5 years) that apply:

  • Policies and Informed Consent

    Please review, sign and date this form to submit.

  • Massage Policies:

    After you sign and date below, please click "Submit", scroll to the bottom of the pop-up confirmation page and click "Sign Document". Once completed, you will receive an email with a copy of your intake form from "Jotform."

    All client services and chart information are kept strictly confidential. Written authorization is required from you the client for the release any information.

    • Please silence your cell phone for the full benefit of your session.
    • Please be on time. A late start will result in a shorter session and subject to full payment. 
    • 24 hour cancellation notice is required to avoid being charged for your session.
    • No shows and late cancellations are subject to full payment and will be charged to the card on file. 
    • You will be fully draped during your session and at no time will genitalia or breast tissue be exposed.
    • Once the therapist has left the room, you may disrobe to your comfort level to get on the table.
    • You will have a breif intake/exit consultation during your session to discuss any special needs, areas of concern and outcomes.
    • I understand that I may or the the massage therapist may end the session at any time and for any reason.
    • Communication or behavior of a sexual or suggestive nature is strictly prohibited. If such conduct occurs, the session will be ended immediately, and the client will be responsible for full payment of the scheduled services - no exceptions. 

    Informed Consent:

    I undersrtand that I will receive a theraputic massage for the purpose of maintaining good health and physical condition. I also understand that my massage therapists is not legally permitted to diagnose or prescribe any medical treatment for any illness, injury or disease.

    I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. I have stated my pertinent medical conditions and will update the massage therapist of any changes in my health status. I understand failure to do so may pose a risk to my health or physical wellbeing. I hold harmless Akros Bodywork and my massage therapist from any liability whatsoever arising from the failure to disclose on my part.

    I understand that a proposed session plan and any cautions or contraindacations will be address prior to my session. It is my choice to receive therapeutic massage as a form of therapy, and I may request alteration of any aspect of the massage.

    I undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapist so they may adjust as required, or I may discontinuation the session at any time.

    By entering my typed electronic signature below, I hereby give consent to receive theraputic massage from Akros Bodywork and agree to the massage policy and informed consent above.  

  •  - -
  • Should be Empty: