Hawaii Natural Therapy Logo
Hawaii Natural Therapy Logo

MASSAGE INTAKE FORM

Coming for a couple's massage? Please submit this form for each of you.

    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.

    NEXT STEPS

    We'll get back by phone or by email within 30 minutes. To expedite your request, feel welcome to call the clinic directly at 808.200.4611 or use our free mobile app.

    Massage appointments are processed daily between 8:45 am and 6 pm.

    Getting Here

    Get directions and free parking information.

    Our Clinic

    Visit massage clinic of Hawaii Natural Therapy.

    Our Team

    Meet our licensed massage therapists.
    Schedule First Session
    30 | 60 | 90 | 120 minutes – prices | members

    Gift Cards

    Do you know a better gift than a relaxing massage? Surprise your loved ones with online gift certificates or beautiful printed gift cards. Add a thoughtful personal message.

    Learn About Massage

    Check Frequently Asked Questions about Massage and appointments at Hawaii Natural Therapy.

    Mobile App

    Book your massage instantly 24/7 and save with our specials with new free mobile app.
    Hawaii Natural Therapy on iTunesHawaii Natural Therapy for Android on Google Play
    © Copyright 2014 - 2021. All Rights Reserved.
    Hawaii Natural Therapy
    linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram