Client Intake Form Barrelogic (Page 3 of 3) in pdf

Client Intake Form Barrelogic Page 3

Contract for care:

I promise to participate fully as a member of my health care team. I will make sound choices

regarding my treatment plan based on the information provided by my Massage Therapist and

other members of my health care team. I agree to participate in the self-care program that we

select. I promise to inform my health care team any time I feel my well-being is threatened or

compromised. I expect my Massage Therapist to provide safe and effective treatment.

Consent for care:

It is my choice to receive massage therapy, and I give consent to receive treatment. I understand

that Massage Therapists DO NOT diagnose illness, disease or any other physical or mental

disorders. Massage therapy is not a substitute for medical examination and/or diagnosis. I

affirm that I have stated all my known medical conditions and shall take it upon myself to keep

my Massage Therapist updated on my physical/mental health. I also agree there shall be no

liability on the practitioner’s part should I neglect to do so.

Client Signature______________________________ Date_______________________

Cancellation Policy:

Your business is valued and your cooperation is appreciated. A 24-hour cancellation notice is

required for any scheduled appointments including gift certificate sessions. Missed or no-show

appointments will result in you being charged the full amount of the session booked unless the

session can be filled. Emergency callcellations are determined at the Massage Therapist’s

discretion.

Client Intake Form Barrelogic Page 3