Massage Therapy Intake Form Page 2

Please indicate on the diagrams areas of pain/tension:

I understand that massage therapy is an aid to health, given here for stress

reduction, relief from muscle tension, spasm or pain or for increasing

circulation. Massage Therapists do not diagnose illness or disease and are

not a substitute for medical examination or diagnosis. I have stated all my

known medical conditions and will keep the massage therapist updated on

any changes.

Appointment policy- If you miss a scheduled

appointment or make a cancellation within 24 hours

you will be charged 100% of your treatment fee.

Signature

Date:___________________

:_________________________________

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