If you are unable to
complete the online
electronic form please download, print and bring in the form below with you to your appontment.

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Massage Intake Form

Present Health Conditions: Please mark all that apply: Musculoskeletal

Present Health Conditions: Please mark all that apply: Circulatory

Present Health Conditions: Please mark all that apply: Respiratory

Present Health Conditions: Please mark all that apply: Skin

Present Health Conditions: Please mark all that apply: Nervous System

Present Health Conditions: Please mark all that apply: Digestive

Present Health Conditions: Please mark all that apply: Reproductive

Present Health Conditions: Please mark all that apply: Other

I understand that massage therapy provided by the massage therapist is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch.The general benefits of massage, possible massage contraindications and the treatment or medications, and that it is reccommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not a part of massage therapy.I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes.I have received a copy of the therapist's policies, I understand them and agree to abide by them.I understand that if the massage therapist starts a session late, she will make it up to me at the end of my session if possible, or will reduce my fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time so that the client following me is not penalized. I agree to give a 24 hour notice for a scheduled session that I cannot keep. I am aware that I will be charged a fee of $20 for any missed sessions or for sessions that I do not give a 24 hour notice to cancel or reschedule.