top of page

Massage Intake Form

Massage Therapy Intake Form

Date

Client Contact Information

Emergency Contact

Questionnaire

Have you had a massage before?
yes
no
Do you exercise or play sports?

Client Medical History

Birthday
Choose any/all of the following you currently have or had in the previous 6 months. If none - select none
Are you currently taking any medication?
yes
no

Policies & Procedures

Cancellation Policy

We understand that life can be unpredictable, and plans may change. In order to provide the best service to all of our clients and honor the time set aside for your session, we kindly ask that you adhere to the following cancellation policy:

  1. Cancellation Notice: If you need to cancel or reschedule your appointment, please provide at least 24 hours' notice prior to your scheduled time.

  2. Late Cancellations: Cancellations made within less than 24 hours of the scheduled appointment will incur a cancellation fee of 50% of the total service cost. This fee will be charged to the card on file or must be paid before rescheduling.

  3. No Shows: Failure to show up for an appointment without prior notice will result in a charge of 100% of the total service cost. No further appointments can be scheduled until this fee is paid.

  4. Emergency Exceptions: We understand that emergencies happen. If you experience an unexpected situation that requires last-minute cancellation, please reach out to us as soon as possible, and we will handle it on a case-by-case basis.

By booking an appointment, you agree to adhere to this cancellation policy. Thank you for understanding and supporting the smooth operation of our practice.

Massage Therapy Service Agreement

By booking your session, you acknowledge and agree to the following terms regarding the massage therapy services provided:

  1. Therapeutic Services Only: I understand that the massage therapy services provided are intended solely for therapeutic and relaxation purposes. These services are not a substitute for medical treatment or diagnosis and should not be interpreted as such. The massage therapist does not diagnose, prescribe, or treat medical conditions, illnesses, or injuries.

  2. Medical Advice: I acknowledge that it is my responsibility to seek professional medical advice from a licensed healthcare provider for any medical concerns or conditions that I may have. The massage therapist will not recommend or prescribe medications or medical treatments.

  3. Communication of Medical Conditions: I agree to fully inform the therapist of any known medical conditions, injuries, or changes in my health status prior to the session. I understand that failure to disclose this information may affect the safety and effectiveness of the session.

  4. Changes in Medical History: I agree to notify the therapist immediately of any changes in my medical history or physical condition that may impact my ability to receive massage therapy. This includes but is not limited to new diagnoses, surgeries, injuries, or medications.

  5. Client Responsibility: I understand that I am responsible for communicating any discomfort or concerns during the session and that I may request a modification or discontinuation of the treatment at any time.