Massage Intake Form - No Insurance

Name*

First NameMiddle NameLast Name

Birth Date*

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact*

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Medications Currently On

Allergies

1. . List Areas of Discomfort or Pain (Reason for your appointment. Ex: Relaxation)*

2. Describe Onset of Discomfort or Pain

ConstantOff/OnAt RestWith Activity

MorningAfternoonEveningDuring Sleep

6. Have you ever injured this area before?

7. Is there anything that you do that creates, increases or decreases pain?

8. Are you currently seeing any other healthcare professional for your pain?

9. Is there any additional information I should be aware of before your massage treatment?

Massage Policies

Client services and chart information are confidential. Written authorization from you is required to release any information.

• Please turn off your cell phone for optimal relaxation.
• Your scheduled session time is reserved exclusively for you. We do not double-book appointments.
• Please reschedule your session if you are more than 15 minutes late.
• A minimum of 24 hours’ notice is required for cancellations to avoid being charged for your session.
• You will be draped at all times; genitalia and breast tissue will never be exposed.
• You will have a consultation with your therapist to discuss your session prior to beginning.
• If the session requires it, you may disrobe to your comfort level after the therapist has left the room.
• I understand that either my massage therapist or I may end the session at any time for any reason.
• Inappropriate behavior will not be tolerated and may be prosecuted to the fullest extent of the law.

Client Agreement

I understand that therapeutic massage therapists do not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that I consult a physician for such services.

It is my choice to receive therapeutic massage as a form of treatment.

I understand that any treatment provided is designed to address the care and prevention of myofascial pain and dysfunction.

I also understand that if at any time I feel pain or discomfort during the session, I will immediately inform my massage therapist so that adjustments can be made.

I have stated all pertinent medical conditions and agree to update my massage therapist regarding any changes in my health status.

I understand that failure to do so may pose a risk to my health and/or physical well-being, and I agree to hold harmless Salud Mobile Massage and my therapeutic massage therapist from any liability arising from such failure on my part.

By my electronic signature below, I agree to the Massage Policies and Client Agreement above.

Today's Date*

Date

Signature*

Massage Intake & Insurance Form

All information is treated with the strictest confidentiality. No details will be disclosed or shared without the client’s written consent. You may choose to refrain from answering any question that you feel encroaches on personal information you prefer not to disclose.

History of Pathology