Massage Intake Form Name * First Name Last Name Phone * (###) ### #### Email * Zip Code Is this your first massage? * Yes No Do you have a pressure preference for your service(s)? * Light Medium Firm No Preference Are you currently under the care of a physician? Please list any allergies here: Please list any pain, injuries, or areas of focus you would like addressed in your massage: Do you have any specific treatment goals for your session today? Permissions * I give my permission to receive massage therapy and understand that therapeutic massage is not a substitute for traditional medical treatment or medications. I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications and I have clearance from my physician to receive massage therapy. I understand the risks associated with massage therapy and release the company and the individual massage therapist from all liability concerning any injuries that may occur during the session. I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly. I understand that I or the massage therapist may terminate the session at any time. I have been given a chance to ask questions about the massage therapy session and my questions have been answered Which service(s) are you currently booked for? * Thank you! Someone will contact you soon!
