Client Intake Form – Massage Therapy

The following information will be used to help plan safe and effective massage sessions.

Please answer the questions to the best of your knowledge.

1. Full Name

2. Gender

3. Occupation

4. Emergency Contact Name and Phone Number

5. Email

6. Cell Phone Number

7. Address

8. Please specify any areas of the body you would like the therapist to target more during your massage.

9. Is there anything else about your health history you think is relevant to plan a safe and effective massage session for you?

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/stokes can be adjusted to my level of comfort. I will not hold my therapist for any pain or discomfort experienced during or after the session.
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 will be no liability on the therapist's part should I forget to do so.
By signing this release, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy and body work.

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