Massage Intake Form Page 2

Massage Intake Form

On a scale of 1-10, 10=deepest, rate the level of pressure for massage:

__________

Please indicate on the diagram areas of pain.

I agree that my therapist is aware of any medical conditions. I agree to inform my therapist of

any medical changes including medications. I understand that the services today are not a

substitute for medical care. I understand that the massage is entirely therapeutic and non-

sexual.

Name (Printed):

_______________________________________

Signature:

_______________________________________

Date:___________________________________

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Parent category: Business