Massage Client Intake Form (Page 4 of 4) in pdf

Please r ead a nd i nitial:

_______ I u nderstand t he m assage, c raniosacral t herapy, l ymph d rainage, o r R eiki i s f or t he

purpose o f s tress r eduction, e motional h ealing, r elaxation o f m uscles, b etter c irculation o f l ymph,

cranio f luid, a nd e nergy t hroughout t he b ody.

_______ I u nderstand t hat m assage, c raniosacral t herapy, l ymph d rainage, o r R eiki d oes n ot

diagnose i llness, d isease, o r a ny o ther p hysical o r m ental d isorders. I n a ddition, t he m assage

therapist d oes n ot p rescribe m edical t reatments o r p harmaceuticals.

_______It i s u nderstood t hat a ny i llicit o r s exually s uggestive r emarks o r a dvances o n t he c lient’s

part w ill r esult i n i mmediate t ermination o f t he m assage s ession, a nd t he c lient w ill b e l iable f or

payment o f t he f ull s cheduled a ppointment.

_______I u nderstand t hat m assage, c raniosacral t herapy, l ymph d rainage, o r R eiki i s n ot a

substitute f or m edical e xaminations a nd/or d iagnosis a nd t hat i t i s r ecommended t hat I s ee a

physician f or a ny p hysical a ilment t hat I m ight h ave.

_______Because t he t herapist m ust b e a ware o f e xisting p hysical c onditions, I h ave s tated a ll m y

known m edical c onditions a nd t ake i t u pon m yself t o k eep t he t herapist u pdated o n m y p hysical

health. F urther, I r elease t he t herapist f rom r esponsibility a nd l iability f or a ny a dverse r eactions

resulting f orm d isclosed a nd u ndisclosed c onditions.

Client S ignature:___________________________________________________Date:________________

Practitioner S ignature:________________________________________________Date:_______________

Consent t o T reat a M inor

By m y s ignature b elow, I h ereby a uthorize E lizabeth B osse, L MT t o a dminister m assage o r

craniosacral t herapy t o m y c hild o r d ependent a s t hey d eem n ecessary. I u nderstand t hat I , a s t he

parent o r g uardian, m ust b e i n t he r oom d uring t he s ession.

Signature o f P arent o r G uardian: _ _____________________________________Date:________________

Massage Client Intake Form Page 4