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Subject

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Referred By

Physician

Reason for Appointment

If above is related to accident or injury, please describe how and when injury occurred.

History of surgery

List any medications

Current Chiropractor or Physical Therapist if being treated.

Any other medical condition I need to be aware of?

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I understand that massage therapy is provided for relief from pain or muscular tension. I understand that a massage therapist can not diagnose illness or disease and can not prescribe medical treatment. I understand that massage is not a substitute for medical exam and it is recommended that I see my physician for any physical ailment. Because a massage therapist must be aware of existing conditions, I have stated all known medical conditions and that I am responsible for informing the therapist of any changes. I am also aware that any form of inappropriate sexual advances will not be tolerated and will terminate my treatment permanently. I agree to refrain from receiving massage services while in a contagious state of any illness or condition. PAYMENTS ARE DUE AT TIME OF SERVICE First sessions include overall postural assessment and discussion of client intake form. This is part of your session and will necessarily shorten the actual time on the table for the client. These assessments normally do not take longer than 15 mins. Arriving a few mins early will help with this. I accept cash, checks and credit cards and apple pay. Any bank fees for insufficient funds, returned checks you will be responsible for paying prior to your next session.

CLIENT INFO FORM

Hours