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New Client Intake Form

Please complete this consent form before your appointment. All required fields must be completed before submitting.

This field is for validation purposes and should be left unchanged.
Name(Required)
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Address(Required)
Sex
Have you visited our office?
Any specific areas of tension/pain?

Do you have Insurance?
Terms and Conditions (Required) By signing below, you agree to the following:I voluntarily request and consent to receiving massage therapy.I understand that the massage services provided are intended for general wellness, stress reduction, and relief of muscular tension only.To the best of my knowledge, I do not have any injuries or conditions that would prevent me from safely receiving massage therapy. I understand the importance of informing my massage therapist of all known medical conditions and medications, and I acknowledge that additional risks may be associated with my physical condition.If I experience any pain or discomfort during the session, I will immediately inform my therapist so that the pressure or technique may be adjusted to my comfort level. I will not hold the massage therapist responsible for any discomfort I experience during or after the session.I understand that the potential risks associated with massage therapy include, but are not limited to: Minor superficial bruising Short-term muscle soreness Aggravation of an unknown or pre-existing injuryI affirm that I do not have any contagious conditions that could pose a risk to my massage therapist or other clients.I understand that either I or the massage therapist may end the session at any time for any reason.I have had the opportunity to ask questions regarding massage therapy, and all of my questions have been answered to my satisfaction.I acknowledge that I have been informed of the policies and procedures related to massage therapy and that I understand them. I understand that massage therapy is not a substitute for medical care, and that I should consult a physician or qualified health provider for any medical concerns I may have.I further understand that massage therapists do not diagnose or treat illness, injury, or disease, and that nothing said during the session should be interpreted as medical advice or diagnosis. My consent is informed and voluntary, and I understand that I may withdraw it at any time, except for services already provided.By signing below, I give my consent to receive massage therapy as described above.(Required)
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