Client Intake Form (Page 2 of 2) in pdf

Please indicate your areas of concern:

Heath

Please indicate any or all that pertain to you:

Arthritis

Aneurysm

Anxiety

Varicose Vein

Asthma

Dizziness

Numbness

Pinched Nerve

Back Pain

Epilepsy/Seizures

Plates/Screws

Coccyx Pain

Bleeding Disorder

Emphysema

Pregnant

Blood Clots

Heart Attack

Rash/Shingles

Broken Bones

Headaches

Sleeping Disorder

Cancer:

Hernia

Stents/Shunts

Constipation

Spinal Problems

High Blood Pressure

Diabetes

Joint Pain

Stroke

Diarrhea

Kidney Disease

Thrombosis

Other______________________________________

Consent to Massage & Bodywork

I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such

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assessments, examinations and techniques, which may be recommended, by my therapist. I acknowledge that

the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I

clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I

attend my personal physician for any ailments that I may be experiencing.

I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have

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completed my medical history form as provided by my therapist. I have disclosed to the therapist all of those

medical conditions affecting me. It is my responsibility to keep the massage therapist updated on my medical

history. The information I have provided is true and complete to the best of my knowledge.

Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session.

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Late and Cancellation Policy

If you arrive late, the length of your treatment will be reduced to end as scheduled, allowing the therapist to take

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their next scheduled appointment on time.

I understand that unanticipated events happen occasionally in everyone’s life. I respectfully request a 6 hour

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cancellation for your appointment. Consistent no-show or cancelled appointments with less than 6 hour notice will

be booked as walk-in clients only.

Client Signature____________________________________________________________________

Client Intake Form Page 2

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