MASSAGE INTAKE FORM

Client Information

First and last name

Gender
MaleFemale

Complete postal address

Email address

Phone

Emergency contact, first and last name, and relationship

Emergency contact, phone

How did you find us?

Is this your first massage
YesNo

Medical Information

Your date of birth

What are your goals for massage? (relaxation, rehabilitation, sport, ...)

Medical conditions or allergies we should know about

Desired pressure level
12345 (hardest)

Indicate if pregnant
Yes

Liability Waiver and Consent

You agree with the following:

• I understand that session time includes massage and a total of 10 minutes of time for consultation and dressing, which occurs both pre and post session.

• I understand that I am receiving massage treatment at my own risk and agree to hold free the therapist, Hawaii Natural Therapy Clinic, Inc., from any claims, demands, or actions including, but not limited to, claims for personal injury arising from my participation in massage therapy services.

• I understand that the massage treatment I receive is provided for the basic purposes of relaxation and relief of muscular tension. If I experience any pain or discomfort during this and future sessions, I well immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

• I further understand that massage treatments should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I also understand that massage treatments should not be performed under certain medical conditions.

• I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner'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 and I will be liable for payment in full of the scheduled appointment.

• I understand that cancelled or missed appointments without 24 hours notice (medical emergencies excluded) may be charged for the price of the missed session.

• I affirm that I have stated all my known medical conditions and have answered all questions honestly.

I agree to the conditions.