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  • Client Intake Form

    About you...

    All information is confidential.

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  • Are you currently experiencing symptoms of any of the following conditions? If you currently are ill your session MUST be rescheduled for 48 hours after symptoms subsides.

  • Certain medical conditions or symptoms may be aggravated or get worse by receiving a massage. A referral from your primary care provider may be requested before your session. You are encouraged to check with your doctor to be sure massage therapy is appropriate for you. This includes musculoskeletal, circulatory, respiratory and skin conditions. If your condition is not below please mark other and advise.


  • The following sometimes occurs during massage.
    They are normal responses to relaxation.
    Trust your body to express what it needs to:
    need to move or change position - sighing, yawning, change in breathing, stomach gurgling - emotional feelings and/or expression,movement of intestinal gas, energy shifts - falling asleep, memories

    Client Agreement:

    1. I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and treatment.

    2. This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.

    3. I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my Massage Therapist so they can adjust the pressure to my comfort. I have informed my Massage Therapist of all known medical conditions and understand it is my responsibility to keep my Massage Therapist updated on my physical health. I understand that my failure to do so may pose a threat to my health and/or physical well being and I hold harmless my Massage Therapist from any liability whatsoever arising from failure on my part.

    Massage Policies:

    Client services and chart information are confidential. Written authorization is required from you to release any information.

           • Please reschedule your session if you are more than 15 minutes late

           • 24 hour cancellation notice is requested to avoid being charged for your session


    By Hitting the SUBMIT button below, I agree to the massage policy and client agreement above.

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