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Massage Intake Form

Medical History

Massage and bodywork therapy practices are designed to promote and maintain the health and well-being of the client. These therapies do not include the diagnosis of illness, disease, impairment or disability. If I experience any reactions, pain or discomfort during this session, I will immediately inform the therapist so that the products, pressure and/or manipulations may be adjusted to my level of comfort. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, I affirm that I have informed the therapist of all my known medical conditions and will keep the therapist updated as to any changes in my medical condition.

By signing below, I acknowledge that I have read the above information and give my consent to be treated. This consent form is valid for future treatment, but I will alert the staff is there are any future changes to my medical history. Thank you for completing this questionnaire; by doing so, your therapist can give you the most personalized and effective treatment possible. Your privacy, including the information on this form is strictly confidential, and will not be shared without your permission.

April 21, 2021