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

Massage Therapy Intake Form Page 2

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.

Signature:_____________________________________________________________Date:____________________________________________

Signature of parent/guardian:_____________________________________________Date:_____________________________________________

(if patient is a minor)

If you are unable to keep your appointment, please give 24 hours notice.

Massage Therapy Intake Form Page 2