Intake Form and WaiverPlease fill out this form prior to your first visit. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Emergency Contact * Have you had professional massage before? * Yes No Please list any major injuries/accidents or surgeries Do you have any allergies or hypersensitiveness? Please list any current medications Please read and initial in acknowledgement of the following information: * I understand that the services offered today are not a substitution for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or to treat physical or mental illness. 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 and 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 agree to inform my therapist of any changes in my health and medical conditions. 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. 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. * Please type your name and date below. Thank you!
