Client Intake Form Massage Therapy – Recovery House Just for You

Elite Massage Services Client Intake Form

Name *

First

Last

Date *

Phone Number *

Date of Birth *

Address *

City *

State *

Zip Code *

Email *

Dates of service *

example: 3 days 1/2/2019,1/3/2019,1/4/2019

1. Have you had a professsional massage before? YES / NO (The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge. )

2. Do you have any allergies to oils, lotions, or ointments? YES / NO

3. Have you had any surgeries in the past 5 years? YES / NO

If you answered yes to question 3 please enter your last 3 surgerys,

SX Date: _____________ Procedure:___________________________ Doctor:______________________

4. Please list any medical issues of which we should be aware: *

5. How did you hear about us:

Draping will be used during the session if necessary- only the area being worked on will be uncovered. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17. I patient understand that the massage I receive is provided for the basic purpose of relieving tightness, stiffness and swelling. 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 further understand that each session should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that the massage therapist are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. I understand I release all liability and responsibility to the therapist if any injury occurs during any/each session. I read and understand the above statement. *

Yes, I understand and agree.

Name *

First

Last

Yes , I understand and agree with both check box and electronic signature.

Date *

Phone

Service Areas

Contact Info

Customer Service Hours