Massage Client Intake And Waiver Form (Page 2 of 2) in pdf

Massage Client Intake Form

Massage Client Waiver Form

Please take a moment to read and initial all of the following statements:

If I experience pain or discomfort during the session, I will immediately inform my therapist so that

pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for

any pain or discomfort I experience during or after the session.

_____

I understand that the services offered today are not a substitute for medical care. I understand that

my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat

physical or mental illness.

_____

I affirm that I have notified my therapist of all known medical conditions and injuries.

_____

I agree to inform the therapist of any changes in my health and medical condition. I understand that

there shall be no liability on the therapist’s part should I forget to do so.

_____

I understand that massage is entirely therapeutic and non-sexual in nature.

_____

By signing this release, I hereby waive and release my therapist from any and all liability, past, present,

and future relating to massage therapy and bodywork.

_____

I understand that should I cancel an appointment less than 24 hours before the scheduled time or “no

show” an appointment, I am subject to a fee equal to the cost of the missed appointment. This fee is

monetary & can’t be taken as an additional “punch” off a massage package card. If the

appointment was booked under a gift certificate, it will be voided in lieu of the fee.

_____

Information and Suggestions

•

Prior to your massage, please remove contact lenses and all jewelry. Pull long hair back with a clip or

band.

•

In general, massage is given while you are unclothed. However, you may choose to wear undergarments

or a swimsuit. You will be covered with a top sheet throughout your session. This is your massage and

you should be as comfortable as possible.

•

Feel free to ask your therapist any questions before, during, or after the session. Your therapist is a highly

trained professional and will be happy to make you feel informed and comfortable.

I have received the policy statement, and have read and agree to the policies therein.

Client name:____________________________________________________________________

Client signature:_________________________________________________________________

Date:__________________________________________________________________________

Therapist signature:______________________________________________________________

Massage Client Intake And Waiver Form Page 2