Client Intake Form (Page 2 of 2) in pdf

Please describe how you are feeling today, and note any places of tension, pain, discomfort, etc. on the

diagram below:

Comments:

______________________________________________________________________________________

Waiver and Release

I, ____________________________________________________________________________, understand that massage

is provided for the basic purpose of relaxation, stress reduction and relief of muscular tension. If I experience any pain or

discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be

adjusted to my level of comfort.

Massage services are not meant to take the place of a physician’s care. Information exchanged during a massage is

educational in nature, not diagnostic or prescriptive, and is to be used at my own discretion. Because massage should not

be performed relative to certain medical conditions, I affirm that I have stated all my known medical conditions and

answered all questions honestly. I understand that it is my responsibility to keep the massage therapist updated as to any

changes in my medical profile.

I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of

the session.

I hereby waive and release my massage therapist, Centre Ave. Massage & Spa and anyone affiliated with it, from any and

all liability, past, present and future, relating to massage therapy and body work.

Signature: ______________________________________________________

Date: ____________________________________

If client is a minor (under 18 years of age):

By my signature below, I hereby authorize Centre Ave. Massage & Spa to administer massage/bodywork, or somatic

therapy techniques to my child or dependent, _________________________________________________________, as

they deem necessary.

Signature of Parent or Guardian _____________________________________________ Date ____________________

Client Intake Form Page 2