Address

Phone

DOB (mm/dd/yyyy)

Occupation

Email

if yes, please explain.

If yes, please list the medications.

List areas to be avoided during this session

Please indicate any areas in which you are currently feeling discomfort.

Where do you usually hold tension?

Preferred level of pressure

How did you hear about us?

Signature

I understand the benefits and risks of massage and give my consent for massage. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or techniques may be adjusted to my level of comfort/tolerance. I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapist are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical mental illness, and that nothing said in the course of the session given should be construed as such. Understanding that massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

Please fill out the following intake form before seeing a therapist.