Medical Massage Intake

Medical Massage Intake Form

Please complete all information and sign before submitting.
Client's Information
Name

First NameLast Name
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information

Please add all the information for the subscriber (person responsible for insurance) in the fields below
Name

First NameLast Name
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to patient
If self, type self
Insurance Provider
Name of company on insurance card
Insurance provider customer service number
Please enter a valid phone number.Format: (000) 000-0000.
Group Number
Member/Subscriber ID Number
Have you had a massage before? If so, when was the last time?
Please list any allergies or if you have sensitivies to fragrance
Do you have any medical implants or hardware I need to be aware of?
Pacemaker, metal from injuries, etc
If you have any medical diagnosis or issues, please list them here
What are your concerns for this visit?
any pain, discomfort,tension, etc
What are your treatment goals?
pain relief, stress reduction, better sleep, etc
What type of pressure do you prefer?
light, medium or deeper pressure
Are there any areas of the body you would like to be avoided?
Such as hair, feet, etc
- I understand that the massage service offered is for the therapeutic purpose of general wellness, stress reduction, and relief of muscular tension.
- Information about massage therapy, potential benefits, effects, risks, contraindications, and possible alternative therapies have been explained to me and I understand this information.
- I understand the risks associated with massage therapy include, but are not limited to: superficial bruising, short-term muscle soreness, and exacerbation of undiscovered injury.
- I have been given the opportunity to ask questions about massage therapy and my questions will have been answered to my satisfaction.
- If I experience any pain or discomfort, I will immediately inform my therapist so that the pressure or techniques can be adjusted to my comfort level.
- I will not hold my massage therapist responsible for any pain or discomfort I experience during or after the session.
- I have provided my therapist with an accurate and complete medical history and agree to inform my therapist of any new diagnoses, or changes in my health or medications.
- I do not have any injuries or conditions that prevent me from receiving massage therapy.
- I understand the importance of informing my massage therapist of all medical conditions and medications that I am taking, and that there may be additional risks based on my physical condition.
- I understand that I or the massage therapist may terminate the session at any time.
- I release the massage therapist and business from all liability for any harm that may unintentionally result from this treatment.
By signing this form I agree to the conditions as outlined above, and I release the massage therapist, Mary K Curry and Sea Breeze Beauty from all liability for any harm that may unintentionally result from this treatment.
Signature
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Medical Massage Intake Form

Client's Information

Insurance Information