Massage Intake Form

Residential Zipcode *

Date and time of your current appointment *

Is this your first massage?

Yes

Do you have a pressure preference for your service today? *

Light

Medium

Firm

Are you currently under the care of a physician? If so, please explain *

Please list any allergies we should be aware of *

Do you have any of the following conditions: *

Pregnant or Nursing

Heart Condition

Vericose Veins

Diabetes

Metal plates or pins

Epilepsy

None Applicable

Are you currently on any of the following medications: *

Muscle Relaxants

Pain Medication

Antihypertensives

Diuretics

Blood Thinners

None Applicable

Please list any pain, injuries or areas of focus you would like addressed during your massage today

Do you have any specific treatment goals for your session today?

I give my permission to receive massage therapy and understand that therapeutic massage is not a substitute for traditional medical treatment or medications. I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications and I have clearance from my physician to receive massage therapy. I understand the risks associated with massage therapy and release the company and the individual massage therapist from all liability concerning any injuries that may occur during the session. I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly. I understand that I or the massage therapist may terminate the session at any time. I have been given a chance to ask questions about the massage therapy session and my questions have been answered *

Complete This Form in Advance of Your Massage Treatment

Massage Intake form