Client Intake & Consent Form

Client Intake & Consent Form

Resolution Massage Therapy
Personal Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
About You
Have you ever received massage therapy?

YesNo
Describe your goals for massage therapy (i.e. relaxation, tension/pain relief, etc)
Do you have any problem areas, injuries or relevant health information you would like your massage therapist to know?*
Medical History
Please tick the following pre-existing conditions that apply to you:*

Heart ConditionsDiabetesHigh/Low Blood PressureChronic IllnessArthritis/OsteoporosisPregnancy (currently or recent)Recent injury, surgery or procedure (past 12 months)None of the aboveOther

Acknowledgement & Consent
Terms of Service
All online bookings are not confirmed until a $55 deposit has been paid and confirmation of your appointment date and time has been sent by us via email.

Cancellations made with less than 12 hours’ notice will result in the deposit being withheld as a cancellation fee.

All booking deposits are transferrable if you need to reschedule so long as 12 hours’ notice is given.

Deposit payment can be made to the following account:

Resolution Massage Therapy

BSB: 112-879

Account No: 400 922 944

(Please use your full name as reference)
Consent
I understand that massage therapy is for relaxation and therapeutic purposes only and is not a substitute for medical care. Massage therapists do not diagnose or treat medical conditions.

I confirm the health information I’ve provided is accurate and agree to update the therapist if anything changes.

I consent to treatment and understand I can pause or stop at any time. I release the therapist from liability for any outcomes related to my session, except in cases of gross negligence.
By submitting this form, I confirm I have read and agree to the above.*

Yes
Client Signature*

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Date*

DayMonthYear
Date
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Personal Details