Massage Therapy Client Intake

Massage Therapy Intake Form

All information is strictly confidential.

Full Name*

First NameMiddle NameLast Name

Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number*

E-mail*

Emergency Contact*

Phone Number*

Allergies*

Type 'none' if not applicable

Medications*

Type 'none' if not applicable

Occupation

What are the physical duties required of your occupation?

List Areas of Discomfort or Pain

Have you ever received therapeutic massage for a specific problem or injury?

Was the treatment used effective?

Is there anything that you do that creates, increases or decreases pain?

What is the goal of your massage?

Please check any areas you would like to focus on:

Upper Body

Lower Body

List any areas you want to avoid.

Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

• Please turn off your cell phone for optimal relaxation

• Your scheduled session is set aside for you.

• 24 hour cancellation notice is required to avoid being charged for your session

• You will have a consultation with your therapist to discuss your session

• Should the session require, after your therapist has left the room, you may disrobe to your comfort level

*Required 2 statements below verbatim by The Texas Department of Licensing and Regulation:

• The client or massage therapist may end the massage session if they feel uncomfortable for any reason; and

• The massage therapist must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature

Client Agreement:

I understand that therapeutic massage 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 massage 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 massage 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 therapeutic massage 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 my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.