Massage Therapy Client Intake

Client Intake Form

All information is held to strictest confidence. At no given point the information is disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information that you do not wish to disclose.

Full Name*

First NameMiddle NameLast Name

Birth Date

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

E-mail*

Emergency Contact*

Emergency Contact Phone*

Occupation

History of Pathology

1. List Areas of Discomfort or Pain*

3. Rate of Pain Today*

4. Frequency - please select the most accurate*

5. At what time of day is the pain at its worse?*

15. Are you currently seeing any other healthcare professional? *

Client Agreement

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

I acknowledge that therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic pilates as a form of therapy.

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

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapist so they adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless my therapist from any liability whatsoever arising from failure on my part.

There is a 24-hour cancellation policy, you maybe charged in case you fail to attend your appointment.

By submitting below, I agree to the above policy and client agreement above.