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Client Intake Form

Date of Visit
Month
Day
Year
Birthday
Month
Day
Year

Reason for Visit

How would you rate your general health?
Poor
Fair
Good
Excellent
Have you ever had a professional massage?
No
Yes
If yes, what is the date of your last massage?
Month
Day
Year

Health History

Cardiovascular
Choose all that apply
Head & Neck
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Musculoskeletal
Choose all that apply
Respiratory
Choose all that apply
Reproductive
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SKIN
Choose all that apply
Miscellaneous
Choose all that apply
Waiver

Please read and sign:

  • I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.

  • If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.

  • I understand that today’s services are not a substitute for medical care and that my therapist is not qualified to diagnose, prescribe, or treat physical/mental illness.

  • I affirm that I have notified my therapist of all known medical conditions and injuries.

  • I agree to inform the therapist of any changes in my health and medical condition and that there shall be no liability on the therapist’s part should I forget to do so.

  • I understand that massage is entirely therapeutic and non-sexual in nature.

  • By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and bodywork.

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Date of Signature
Month
Day
Year
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