Massage Intake Form

    Contact Information

    Emergency Contacts

    Biometric & Health Information

    Please check any conditions you previously experienced or are currently experiencing:


    I understand that the massage therapy given here is for the purpose of stress and pain reduction, relief from muscular tension or spasm, and for increasing circulation and energy flow. I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. The massage therapist does not prescribe medical treatment or pharmaceuticals, or perform spinal manipulation. I understand that massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see an appropriate health care provider for any physical ailment that I might have.

    With this in mind, I agree to receive massage therapy and hold the therapist blameless for any problems that might arise as a result of the massage session.