Clients younger than 18 must have a parent or legal guardian sign in person.
This intake must be completed by a parent or legal guardian in person.
Choose the option that best matches how the client can be contacted. Selecting No
phone will require email as the communication method.
Communication
Emergency Contact
A full emergency contact is required before treatment can proceed.
Tap or click to select the relationship option that best fits.
Massage Experience
Set automatically because you selected first massage.
Select the closest time range.
Helps the therapist understand what may be contributing to muscle, joint, posture, or
repetitive-use strain so the session can be adapted more appropriately.
Health History
General Guidance
Massage therapy is generally safe and can provide therapeutic benefits; however, certain
medical conditions may require modifications to treatment or medical clearance to ensure
safety.
If you are currently under the care of a physician or have a chronic medical condition,
you are advised to consult with your healthcare provider prior to receiving massage
therapy.
You are responsible for informing your therapist of any changes in your health status,
medical conditions, or any discomfort experienced during your session.
Allergies & Sensitivities
Includes massage oils, lotions, and scented products.
This question is required. Please answer Yes or No before continuing.
Relevant Allergy / Sensitivity Details
Accessibility & Accommodations
This helps the therapist prepare any reasonable accommodations in advance if needed.
Disclosed Conditions
Please review and select all medical conditions that apply.
Recent Surgery Details
If you are still taking medication related to this surgery, please disclose it in the
Current Medications section.
Artificial Joints / Hardware Details
Pregnancy Follow-Up Required
Pregnancy was selected in Health History. You must also disclose pregnancy in the Safety
section and enter your due date there before continuing. If this was selected by mistake,
uncheck it here.
No Medical Conditions Declaration
Select this only if none of the medical conditions listed above apply to you.
Important Considerations Based on Your Selections
Please review and acknowledge before continuing.
Current Conditions
Review each field below.
• Enter details where applicable.
• Select N/A if not applicable.
• You must complete each field or mark it N/A.
Pain Source
Is this pain related to any of the following?
Reason to Avoid
Why should this area be avoided?
Safety & Scheduling Guidelines
Conditions That May Delay, Limit, or Prevent Treatment
Please review this section carefully. Some conditions mean you should not attend while
symptoms are active. Other conditions must be disclosed before treatment so care can be
modified safely.
Do Not Attend While Sick
For the safety and well-being of both you and your therapist, please do not
schedule or attend an appointment if you are experiencing any active symptoms of
illness or conditions that may be contagious or unsafe during treatment.If symptoms develop before your appointment, please cancel or reschedule and wait
until you are fully recovered before attending. This helps maintain a safe,
respectful, and professional environment for everyone.
Active infection (including contagious skin conditions)
Post-viral symptoms (including long COVID effects)
Gastrointestinal symptoms (vomiting or diarrhea)
Any contagious or unsafe condition for treatment
Fever or elevated body temperature (100.4°F+)
Cold or flu symptoms (contagious conditions)
Blood clot (suspected or confirmed condition)
Dehydration or hangover-related symptoms
Dizziness, fainting, or physical instability
Recent vaccination with active symptoms
Severe pain or unexplained inflammation
Impairment (alcohol or drug influence)
Conditions That Must Be Disclosed Before Treatment
Do any of the following conditions apply to you?
If yes, select all that apply.
Disclosure Safety Notice
One or more disclosed conditions may increase the risk of complications or require
treatment modification, postponement, medical clearance, or refusal of service depending
on your circumstances. It is your responsibility to disclose accurate information and
follow professional guidance for safe care.
Professional & Ethical Behavior Agreement
Please review the following professional standards.
You agree to provide honest and complete information about your health, comfort level,
and treatment concerns, and to update the therapist if anything changes.
You agree to treat the therapist, treatment space, and clinic property respectfully at
all times.
You understand that the therapist maintains professional boundaries at all times and
may modify, refuse, or end treatment if behavior is unsafe, inappropriate, or outside
professional boundaries.
You understand that failure to disclose relevant medical information may result in
treatment being modified, postponed, or refused for safety reasons.
You accept responsibility for your own safety while on the premises, except where
prohibited by law.
You agree to follow clinic policies and professional guidelines during treatment.
Privacy & Information Protection
Please review how your information is handled.
Your personal and health information will be kept confidential, stored securely, and
used only for purposes related to your care, safety, treatment, and business records.
Your information will not be shared without your written permission unless disclosure
is required by law.
You may request access to your records, and you consent to the collection, storage,
and use of this information for treatment and related business records.
Treatment Consent
What massage therapy is intended to do
Massage therapy may help support relaxation, reduce muscular tension, and promote
general wellness.
Medical care disclaimer
Massage therapy is not a substitute for medical diagnosis or treatment. The therapist
does not diagnose conditions, prescribe treatment, or replace licensed medical care, and
you are responsible for seeking appropriate medical care when needed.
Your responsibility and consent
You confirm that you have shared relevant health information and will inform the
therapist of any changes in your condition. You understand the nature of massage
therapy, acknowledge the potential risks, and voluntarily consent to treatment.
In the event of a medical emergency, emergency services, including 911, may be contacted
if necessary. You accept responsibility for any ambulance, medical treatment, or related
emergency response costs, and you understand the therapist is not responsible for those
costs.
Signature / Initials
Sign below to complete your intake. By signing or initialing, you confirm that the
information provided is accurate and that you agree to all terms, disclosures, and
policies.
Please confirm the acknowledgment above to unlock the signature pad.
Use your finger on touch screens or click and hold your left mouse button to draw your
signature or initials.