Massage Intake Form

Thank you for booking a massage with us. Information collected about new clients is confidential and it will be treated accordingly.

Fields marked with are required.*

Name*

Last name*

Email*

Address

Phone number*

Emergency Contact Phone Number

Gender

Female

Male

Other

Age (if under 18, parent consent form is required)*

Have you had a professional massage in the past?

Yes

No

Do you have any allergies? (oils, lotion, fruit, nuts, skin, etc.)

Yes

No

If so, please explain

What's the main reason for your massage today?

Are there any specific areas you would like me to focus on during your massage?

List any recent injuries/accidents/surgeries

Are you pregnant?

Yes

No

Pressure Preference

Light/Meditative

Medium/Moderate

Deep/Trigger Point

Comment or Question:

Massage Policies: Client services and chart information are confidential. - 24 hour cancellation notice is required to avoid being charged for your session . - You will have a consultation with your therapist to discuss your session . - I understand that my therapeutic massage therapist or I may end the session at any time for any reason. - Inappropriate behavior will not be tolerated and will result in the immediate termination of the massage and the full amount of the service will be charged.

Client Agreement: I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform bone manipulation. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. It is my choice to receive therapeutic massage as a form of therapy. I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist, so they adjust. I have stated my pertinent medical conditions and will update the massage therapist of any changes in my health status. I understand that my failure to do so may pose a threat to my health and/physical well-being and I hold harmless Massage by Daniel and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By typing your full name below, you agree to the terms and conditions listed above and you are electronically signing this document and agree that this signature holds the same legal weight as a handwritten signature*