Please fill out the following signature massage intake form:


Today's Date *
Today's Date
Mobile Nr *
Mobile Nr
Date of Birth *
Date of Birth
Emergency Contact Name
Emergency Contact Name
Emergency Contact Phone Nr
Emergency Contact Phone Nr
MEDICAL INFORMATION
If so, please list name and use:
If so, please explain. What makes the pain better? What makes the pain worse?
If so, please list and indicate general date of occurrence(s):
Please indicate any of the following that apply to you.
MASSAGE INFORMATION
If so, please explain.
BY SUBMITTING, YOU AGREE TO THE FOLLOWING. I UNDERSTAND THAT THE SERVICES OFFERED ARE NOT A SUBSTITUTE FOR MEDICAL CARE. I UNDERSTAND THAT MY THERAPIST IS NOT QUALIFIED TO PERFORM SPINAL OR SKELETAL ADJUSTMENTS, DIAGNOSE, PRESCRIBE, OR TREAT PHYSICAL OR MENTAL ILLNESS. I HAVE COMPLETED THIS FORM TO THE BEST OF MY ABILITY AND KNOWLEDGE AND AGREE TO INFORM MY THERAPIST IF ANY OF THE ABOVE INFORMATION CHANGES AT ANY TIME. I UNDERSTAND THAT THERE SHALL BE NO LIABILITY ON THE THERAPIST’S PART SHOULD I FORGET TO DO SO. IF I EXPERIENCE PAIN OR DISCOMFORT DURING THE SESSION, I WILL IMMEDIATELY INFORM MY THERAPIST SO THAT PRESSURE/STROKES CAN BE ADJUSTED TO MY LEVEL OF COMFORT. I WILL NOT HOLD MY THERAPIST RESPONSIBLE FOR ANY PAIN OR DISCOMFORT I EXPERIENCE DURING OR AFTER THE SESSION. I UNDERSTAND THAT BODYWORK IS ENTIRELY THERAPEUTIC AND NON-SEXUAL IN NATURE. I HEREBY WAIVE AND RELEASE MY THERAPIST FROM ANY AND ALL LIABILITY, PAST, PRESENT, AND FUTURE RELATING TO MASSAGE THERAPY AND BODYWORK.

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