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Body

Massage Intake Form

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The following information will be used to

help plan a safe and effective massage sessions.

Please answer the questions to the best of your knowledge.

      

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If yes, please identify the specific area
by checking the appropriate box below

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Medical History

In order to plan a massage session that is safe and effective,

we need some general information about your medical history.

      

  
      
  
      
      
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Draping will be used during the session – only the area being worked on will be uncovered.

Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.

Informed written consent must be provided by parent or legal guardian for any client under the age of 17.

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I,* understand that the massage I receive is provided

for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this

session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of

comfort. 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 therapists are not qualified to perform

spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in

the course of the session given should be construed as such. Because 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.

      

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Submit form & hand back the tablet

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