Issue link: https://www.massageandbodyworkdigital.com/i/790815
Your Practice Name Here Massage Intake Form Legal name:________________________________________________ Preferred name: __________________________________________ Address: ____________________________________________ ____________________________________________ Today's date: ____________________________________ Preferred telephone number: ____________________________________ Email: ____________________________________ The following questions are based on the most current understanding of gender Assigned sex at birth: Male____ Female____ Intersex ____ Other____ Decline _____ Current gender identity: Male____ Female____ Intersex ____ Other____ Decline _____ Preferred pronoun(s): ____________ Occupation: ____________________________ Birthdate: ___________________________ Age: ________ Height: ________ Weight: __________ Whom may I thank for your referral? _________________________________________________ What major concerns brought you here today? ____________________________________________________________________________________________ In case of emergency, please notify: _______________________ Phone ___________________ I, ___________________________________, (client) understand that massage therapy is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation, and offer a positive experience of touch. The general benefits of massage, contraindications, and treatment procedures have been explained to me. I understand that bodywork is not a substitute for medical treatment or medications. I understand that the therapist does not diagnose illness, does not prescribe medication, and that spinal manipulation is not part of the therapy. I understand it is my responsibility to inform the therapist of all known medical conditions and medications, as well as keeping the therapist informed of any changes. I understand that there shall be no liability on the part of the therapist due to my forgetting to relay any pertinent information. I understand that it is my own responsibility to communicate with the therapist if I feel any pain or discomfort during the session so that the treatment can be adjusted. I understand that therapeutic bodywork is NONSEXUAL in nature. Any sexual overtures by the client will result in the immediate termination of the session and the therapeutic relationship. Client signature: _____________________________________________________ Date:_______________________ Preferred contact method: Telephone: ________________ Text: _______________________ Email: ______________________