Completing our intake forms will help us to best serve and assess your
health needs so that we can provide you with optimal health services. We will review your information to make sure
there are no existing conditions that prevent receiving massage therapy services. All information is kept confidential.
IMPORTANT: PLEASE NOTE THAT THERE IS A SUBMIT BUTTON AFTER EACH PART;
PLEASE BE SURE TO HIT THE SUBMIT BUTTON AFTER EACH PART.
MASSAGE INTAKE FORM - PART 1
MASSAGE INTAKE FORM - PART 2
POLICIES OF PROTOCOL FORM
I understand that the massage/bodywork
I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort
during the session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level
of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis,
or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical
ailment of which I am aware. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments,
diagnose, or prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because
massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions
honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall
be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances
made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
We
ask for a 48-hour notice if you are not able to make your scheduled appointment. If you fail to cancel or reschedule your
appointment in a timely matter, you will be charged for the full service.
I have read, understand and agree to comply with all client policies of protocol for
this establishment which are listed above.