Massage Intake Form

Name *
Address *
Are you a student? *
Have you had a professional massage? *
Do you have any difficulty lying on your front, back, or side? *
Do you have any allergies to oils, lotions, or ointments?
Do you have sensitive skin? *
Please check if you are you wearing any of the following: *
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? *
Do you have any particular goals in mind for this massage sessions? *
Have you ever had any surgery or hospitalization? *
Have you ever been involved in an injury or auto accident? *
Are you currently taking any medications? *
Are you currently under medical supervision? *
Are you pregnant?
Please check any conditions listed below that applies to you: *
Have you flown on a plane recently? *
Please read and type your name below to acknowledge that you have read and understand the following: *
Please read and type your name below to acknowledge that you have read and understand the following:
1. I am aware that draping will be used during the massage session so only the area being worked on will be uncovered. 2. I understand that my feedback is an essential element in my treatment, therefore if at any time I should become uncomfortable during the massage, I may bring it my therapist's attention. 3. If I am unable to keep an appointment, I understand that a 24-hour notice is required, otherwise I will be charged a $50 cancellation fee. 4. It is my responsibility to explain and discuss all physical conditions with my Massage Therapist so that s/he may do his/her job. 5. The Massage Therapist does not diagnose or prescribe for medical illness, disease or any other physical or mental disorder. 6. The Massage Therapist does not do spinal manipulations. 7. Massage Therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for any ailment that you have. 8. I have read and I fully understand this form in its entirety. If at any time there are changes in the information given or in my condition, I will notify my therapist before receiving additional massages and that there shall be no liability on the therapist’s part if I fail to do so.