Relax Massage Therapy Client Health Intake Form (Page 2 of 2) in pdf

Please use the letters provided in the key to identify the symptoms

you are feeling today. Circle the area around each letter,

representing the size and shape of each symptom location.

Notes: _______________

P = pain or tenderness

_____________________

S = joint or muscle stiffness

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

N = numbness or tingling

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_____________________________________________________________

____________________________________________________________

Referral System:

Many of you have helped our practice grow by recommending Relaxing Note to your friends, family, and co-workers. To

thank you in return, when someone puts your name in the “How did you hear about us” line of this health form, we will send

you a $20.00 coupon towards your next visit.

Hot Tub Disclosure:

The use of a hot tub (spa), carries risks that may result in serious injury or death. Elderly persons, expecting mothers,

menstruating females and anyone subject to heart disease, diabetes, low or high blood pressure, strokes, epilepsy, or similar

medical issues should not enter a spa alone and without consulting their physician first. Never use a spa while under the

influence of drugs or alcohol. If you are taking medication of any kind, or being treated for any illness, consult your physician

prior to use of the hot tub (spa). THE UNDERSIGNED hereby ASSUMES FULL RESPONSIBILITY FOR RISK OF BODILY

INJURY, DEATH OR PROPERTY DAMAGE due to the negligence of the releases or otherwise while in the spa/hot tub.

Cancellation Policy:

Your appointment time has been specifically reserved for you. A 24 hour notice is required for schedule changes or

cancellations. There is a $25 fee added to your session for changes or cancellations made with less than 24 hour notice.

I am responsible for paying for any appointment cancellation of less than 24 hours. _______ (initials)

I understand that Relaxing Note L.L.C. abides by the H.I.P.A.A. regulations, and that all my records and information is

confidential. _________ (initials)

I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. I

will inform my health care provider and massage therapist if anything changes in my status. I understand that massage/

bodywork I receive is for the purpose of stress reduction and the relief form muscular tension, spasm or pain and to increase

circulation. If I experience any pain or discomfort, I will immediately inform my massage therapist so that the pressure and/or

methods can be adjusted to my comfort level. I understand that my massage therapist does not diagnose illness or disease,

nor perform any spinal manipulations, and does not prescribe any medications/treatments. I acknowledge that massage is

not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services. If I

am unable to attend my scheduled appointment, I will respect and abide by the set cancellation policies. Sexual advances,

requests for sexual favors and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and

will not be tolerated. I understand that I am receiving massage therapy at my own risk. In the event that I become injured

either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy I hereby hold harmless and

indemnify the therapist, their principals, and agents from all claims and liability whatsoever.

Client Signature: _______________________________________________ Date: ______________

(Relaxing Note Use:)

Photo ID Checked:

No. ______________________

Witness: _________________________

Relax Massage Therapy Client Health Intake Form Page 2

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