HEALTH INTAKE FORM
*Have you had a professional massage before?
If yes, how often do you receive massage therapy?
What have you liked most in your past massages?
What have you liked least in your past massages?
*What would you like to use massage for?
*Do you have a preference to starting face up or face down?
Check the areas that you are experiencing the most discomfort or tension
Feel free to elaborate on anything you checked.
*Do you have any allergies to nuts, oils, lotions or ointments?
If yes, please explain
*Do you have sensitive skin?
If you are currently under medical supervision, list your doctor's name and phone number.
Please list any medications you are currently on.
Please check any conditions listed below that apply to you:
Please explain any of the answers you checked above.
Is there anything else your massage therapist should know about your health and body to provide a safe and effective massage session?
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 strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified 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 changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
I have read and agree
Cancellation Policy: Please arrive between five and ten minutes before your scheduled appointment time in order to ensure a full massage session. • You may cancel your appointment without charge 12 hours prior to your scheduled appointment. Messages are fine;we would rather have you cancel over voicemail than not at all and leave us wondering if you were in a car accident. • Sorry, we cannot go over your appointment time. If you are late, you are out of luck. No deductions of session fee if you are late. Thank you for valuing our time! • If you do not call to cancel your appointment or do not show up for your scheduled appointment, you will be charged full price for the scheduled service. If your credit card you reserved for payment does not successfully authorize for payment, you will be sent a paper invoice. If the paper invoice is not paid within 30 days of receipt, the invoice will be sent to collections. Thank you for ensuring that our business and personal bills are not affected by your inability to be responsible for your own time. • If it is your first visit and you no show or late cancel, any "first time" discounts on your subsequent visit will be null and void.