Intake Form | Kneading Me Time

Intake Form

General Information

Name *

Date of Birth *

Phone Number *

Occupation *

How did you hear about us? *

Have you ever received massage therapy or body work before? *

Yes
No

What kind of pressure do you like? *

Light
Medium
Firm
Very firm (deep tissue only)

List any sport, exercise, or repetitive movement you do *

Medical Information

Do you have any allergies? *

Are you on any medications? *

Yes
No

If Yes, which ones?

Are you pregnant? *

Yes
No

If yes, how many months?

Do you have any of the following conditions? *

Diabetes
Open wounds or sores
Contagious skin conditions
Easy bruising
Recent accident or injury
Recent surgery
Artificial joint
Heart condition
High or low blood pressure
Varicose Veins
Arthritis
Deep vein thrombosis/blood clots
Osteoporosis
Cancer
Headaches/migraines
TMJ
Carpal tunnel
Tennis Elbow
Other
None

Please explain any condition you marked above. *

Informed Consent To Massage Therapy Treatment

I understand that the massage therapist is providing massage therapy services within their scope of practice.

I hereby consent to my therapist to treat me with massage therapy for the specified purposes including assesments, examinations, and techniques, which may be recommended by my massage therapist.

I acknowledge that the therapist is not a physician and does not diagnose illness or diseases or any other physical or mental disorders. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physcian for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the result of treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks.

I acknowledge and understand that the therapist must be fully aware of my existing medical condition/history. I have completed my medical history from as provided above by my therapist and disclosed all of those medical conditions affecting me. It is my responsibility to inform the therapist of updates to my medical history. The information I have provided is true and complete to the best of my knowledge.

I have read the above and noted consent and I have had the opportunity to question the contents and my therapy. By signing this form I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physcial conditions and for which I have sought treatment. I understand that at any time I may withdraw my consent and my treatment will be stopped.

Client name *

Date *