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Client Intake Form

Client Intake Form

Step 1 of 2

50%
Credit Card(Required)
50% of the appointment fee will be authorized to reserve your appointment slot. Your card will not be charged unless you late cancel or no show.
Name(Required)
Emergency Contact Name(Required)
Consent
Preferred form of communication(Required)

Section Break

The following information will be used to help plan safe and effective massage sessions. Please answer the following questions to the best of your knowledge.
If so, how do you think it has affected your health(Required)

Medical History

Check all that apply(Required)
Do you have (check all that apply)(Required)

Consent

A parent or legal guardian must accompany clients under the age of 18 and provide informed written consent.
Consent
I understand that the massage I receive is provided for the basic purpose of relaxation and
relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or stroke may be adjusted to my level of comfort. I further understand that the massage should not be construed as a substitute for medical examination, diagnosis or treatment. I understand that massage therapists are not licensed to perform spinal or skeletal adjustments, diagnose, 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 therapist updated as to any change in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
Type your full name to serve as your signature
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