Client intake Form

Full Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

Appointment

What type of aromatherapy do you want (included in all massage services)

What pressure do you want used mostly in your massage session?

What areas of your body do you want AVOIDED in your massage session (Women’s chest always avoided)

What areas do you want MORE FOCUS during your massage session?

Are there special circumstances of your health that you need other directives for your massage session? If yes, please explain.

Rate your pain this week from 1 as the least pain and 10 as the worst pain.

Rate your stress this week with 1 being the least stressed and 10 being the most stressed.

By signing below, you agree to the following:
• I voluntarily request and consent to receiving massage therapy.
• I understand that the massage service offered is for the purpose of general wellness, stress reduction, and
relief of muscular tension only.
• I do not have any injuries or conditions that prevent me from recelving 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.
• If I experience any pain or discomfort, I will Immediately Inform my therapist so that the pressure or techniques used 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 not received a positive test for coronavirus within the past 14 days, and currently have no symptoms.
• I do not have any contagious conditions that may put my massage therapist or other clients at risk.
• I understand that I or the massage therapist may terminate the session at any time.
• I have been given the opportunity to ask questions about massage therapy and my questions have been
answered.
I have been advised of the policies and procedures pertaining to massage and I understand these policies.
Information regarding massage in general, benefits, contraindications of massage, and possible alternative
therapies have been explained to me. I further understand that massage therapy is not a substitute for a
medical examination or treatment, and that I should see a physician or other qualified health specialist for any
mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness
or disease, and nothing sald during the massage should be construed as such. My consent is informed and
voluntary and I understand that I may withdraw my consent at any time except for actions already taken.
By signing this form I give my consent to proceed with the massage service as outlined above.

Client signature

Thank you so much for filling out this plan for how your massage session will be personalized and customized for you remember Your In Great Hands.

Client intake Form

Please Customize your Massage Session by completing the following