New Patient Forms

Confidential Client Intake and Consent Form

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Gender
Address
Have you ever experienced a professional massage?
Are you under a physician’s care?
Do you have any of the following conditions?

What are the appropriate areas of concern? (Please click H for High, M for Medium, L for Low)

Headache
Upper Back
Lower Back
Knee
Neck/Shoulder
Leg/Thigh
Foot/Ankle H M L

I understand that the massage I receive is to provide for the basic purpose of relaxation, stress reduction, and relief from muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or stokes may be adjusted to my level of comfort.
I have given this information to the best of my knowledge and do not hold the therapist responsible for worsening any condition not stated above. I realize that massage therapy is not a substitute for a doctor’s care and will use it as a valuable addition to my healthcare.
It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.
I understand that a 1 hour massage time includes dressing and undressing. The actual hands on time can be anywhere from 50 to 55 minutes.
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