Name
Age
Phone No
Post Code
Occupation
Emergency Contact Number
GP (Name & Address)
The following information will be used to help plan safe and effective massage sessions.
Date of Initial Visit
If yes, how often do you receive massage therapy?
If yes, please explain
If yes, please explain
If yes, please describe
If yes, please describe
Other
If yes, please identify
If yes, please explain
Medical History In order to plan a massage session that is safe and effective, we need some general information about your medical history.
If yes, please explain
If yes, how often?
If yes, please list
If pregnant, how many months?
Please explain any condition that you have marked above
15. Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
Draping will be used during the session – only the area being worked on will be uncovered.
Informed written consent must be provided by parent or legal guardian for any client under the age of 18.
I, ..................................................... (print name) understand that the massage I receive is provided for the basic purpose
of relaxation and relief of muscular tension. If I experience any pain or discomfort during this massage session, I will
immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further
understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I
should see physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I
understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat
any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because
massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical
conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile
and understand that there shall be no liability on the therapist’s part should I fail to do so. I understand that any illicit or
sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand
that the Affordable Massage reserves the right to refuse to perform massage on anyone whom he/she deems to
have a condition for which massage is contraindicated.
Signature of client
Date
Date Sent:
Date Received:
Signature of (Therapist/ Affordable Massages)
Date
Submit Intake Form
