• Shadi Presha LMT Massage Intake Form

  • *Please fill out all fields

  • Personal Information

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex*
  • Format: (000) 000-0000.

  • Medical Information

  • Are you taking any medications?*
  • Are you currently pregnant?*
  • Do you suffer from chronic pain?*
  • Have you had any orthopedic injuries?*
  • Please indicate any of the following that apply to you.

  • Massage Information

  • Have you had a professional massage before?*
  • What type of massage are you seeking?*
  • What pressure do you prefer?*
  • Do you have any allergies or sensitivities?*
  • Are there any areas (feet, face, abdomen, etc.) you do not want massaged?*

  • Shadi Presha General Liability Release Form

  • By signing below, you agree to the following:
    I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

  • By signing below, you agree to the following:


    1) I give my permission to receive massage therapy.

    2) I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.

    3) I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications.

    4) I have clearance from my physician to receive massage therapy.

    5) I understand the risks associated with massage therapy include, but are notlimited to:

    • Superficial bruising
    • Short-term muscle soreness
    • Exacerbation of undiscovered injury

    I therefore release the company and the individual massage therapist from all liability concerning these injuries that may occur during the massage session.

    6) I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition.

    7) I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly.

    8) I understand that I or the massage therapist may terminate the session at anytime.

    9) I have been given a chance to ask questions about the massage therapy session and my questions have been answered.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Therapist's Signature

  • Image field 66
  • Should be Empty: