Massage Intake Form
Please read and complete this form before your appointment
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
First Name
Last Name
Have you had a massage before?
Do you have any hardware or medical devices I need to be aware of?
Metal from injuries, pacemaker
What are your concerns for this visit?
discomfort, pain, tension
For Ashiatsu massage clients, what are your treatment goals?
pain relief, stress reduction, better sleep
For Ashiatsu massage clients, what kind of pressure do you prefer?
light, medium, or deeper pressure
Are there any areas of the body you would like 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.
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