Client Update

Full Name*

First NameLast Name

Today's Date*

Date

Email*

example@example.com

1. Reason for Visit (Choose all that apply):*

2. Primary area(s) of pain/discomfort:*

3. What is the severity of your pain/discomfort?*

4. Can do all daily tasks and activities:

5. What is your current level of STRESS?*

6. Please note any updates or changes to your health information, concerns, conditions or medications since your last visit. (If no changes please enter "none"):*

7. What are your current goals for this massage session?:*

8. Is there anything else you want me to know know before our session?

Informed Consent:

I understand 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 choose to discontinue the session at any time and at my discression.

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

Full Name:*

Date*

Date