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

Provide any other information that may assist the therapist in providing you with a

massage that fits your needs and requirements:

________________________________________________________________________

Informed Consent: Please take a moment to carefully read the following and sign

where indicated.

The above information is accurate to the best of my knowledge and I freely give my

permission to be massaged. Since massage is contraindicated for some serious medical

conditions, it may be necessary to obtain a doctor’s release or prescription before

beginning massage. I understand that massage therapy should not be construed as a

substitute for medical examination, diagnosis, and treatment, and that I should see a

medical or chiropractic physician or other healthcare specialist. I agree to update the

massage therapist in regard to changes in my health and understand that there shall be no

liability on the therapist’s should I forget to do so.

I understand that:

• The relationship between the client and massage therapist is a confidential one

and that all information provided to the therapist are to be kept confidential

• My body will be properly draped at all times for comfort, security, and warmth

• The massage is solely for the purpose of therapeutic massage and that the

massage therapist also has the right to be free from any unwanted, harmful,

offensive, and/or physical contact or behavior. This will result in a termination of

the session

• I will inform the therapist of any discomfort, so that the application of pressure or

stroke may be adjusted to my level of comfort

• The benefits of massage and discomfort that I may feel have been explained

• Should I have to cancel and appointment for any reason, I agree to give the

therapist a 24-hour notice or I will be billed 50% of the cost of the appointment

missed

• By signing this form, I give consent for future sessions. I have read this form and

hereby freely give my permission to be massaged

________________________________

____________________________________

Print Name

Sign Name

_______________________

____________________________________

Date

Therapist’s Signature

Massage Client Intake Form Page 2