Client Intake Form

Intake Form

Step 1 of 5

Including the year of your birth

Client Waiver Form

Please take a moment to read and initial the following information:

General Liability Form

  • I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
  • If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
  • I have been given a chance to ask questions about the massage therapy session and my questions have been answered.
  • I understand the risks associated with massage therapy include, but are not limited to:
  • Superficial bruising
  • Short-term muscle soreness
  • Exacerbation of undiscovered injury
  • I understand that the services offered today are not a substitute for medical care.
  • I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
  • I have clearance from my physician to receive massage therapy.
  • I affirm that I have notified my therapist of all known medical conditions and injuries.
  • I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.
  • I understand that massage is entirely therapeutic and non-sexual in nature.
  • I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19.
  • I understand my therapist shall drape the breasts of all female clients and not engage in breast massage of female clients
  • I understand draping of the genital area and gluteal cleavage will be used at all times during the session for all clients.
  • I understand that I or the massage therapist may terminate the session at any
    time for any reason.
  • I understand the massage therapist will immediately terminate the session if any verbal or physical contact is sexual in nature.
  • By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork. Prenatal Massage Release Form

Prenatal Massage Contraindications

Massage therapy during pregnancy has been shown to be beneficial for a number of common complaints such as fatigue, musculoskeletal pain, sciatica, edema, and many others. However, there are risks associated with specific conditions that may occur during pregnancy.

You must inform your massage therapist/practitioner if you have or have had in the past any of the following conditions or symptoms which may make massage therapy during pregnancy contraindicated or may require your therapist/practitioner to alter the massage.

  • History of miscarriage   
  • Preeclampsia
  • Gestational Diabetes   
  • History of any high-risk pregnancy
  • Cardiac, pulmonary, liver, or renal disorders 
  • Drug exposure
  • Mother’s age under 20 or over 35 
  • Multiples
  • Pitting edema   
  • Hypertension
  • Epilepsy or other convulsive disorders 
  • Genetic abnormalities
  • Placental or cervical dysfunction 
  • Fetal growth retardation
  • Abdominal pain 
  • Bloody discharge
  • Leaking of amniotic fluid 
  • Sudden weight gain
  • Fever 
  • Diarrhea
  • Sudden edema/swelling 
  • Decrease in fetal movement over 24-hour period
  • Severe headaches 
  • Severe nausea or vomiting

Client’s Release
I, ________, have read the aforementioned conditions and symptoms which make massage therapy during pregnancy contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions.
I have disclosed all high-risk factors of my pregnancy.
I have discussed with my prenatal healthcare provider/physician any health concerns that I had about receiving massage therapy. I agree that my healthcare provider/physician has given me clearance to receive massage therapy.
I understand the information contained on this form and confirm that (1) I am receiving medical care including regular check-ups with a licensed healthcare provider. (2) I have not experienced any of the listed symptoms, conditions, or complications. (3) I am not currently experiencing any of the listed symptoms, conditions, or complications. (4) I am experiencing a low-risk pregnancy.
I understand that I will be receiving massage therapy as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of all liability for any harm that may unintentionally occur during my treatment(s).

Minor Release Form

All persons under the age of 18 are required to have a parent or guardian fill out this form.

By signing below, you agree that you are the parent or legal guardian of the minor receiving treatment(s) at our facility. You understand that you are required to remain at the facility for the entirety of the minor’s treatment(s). You will also be required, if needed, to assist the minor in preparing for his/her treatment(s). We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor.
You also agree that you have completed the Intake Form and have informed the therapist of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s).

I ________________________, certify that I am the parent or legal guardian of _____________________, who is ____ years of age as of today. I have completed the Intake Form for the above-mentioned minor and informed the therapist of all relevant medical history and concerns. I understand the scope of massage therapy and that it is not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care. I give permission for my minor child to receive treatment(s) at this facility and agree to all the above terms.