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Making Healthier Choices

Massage Intake Form

Massage by Karen
Massage Rates
Massage Intake Form
Subjects on Health
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About Karen
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Contact Karen

Bring completed and signed forms with you on your first visit.

Massage Therapy Client History/Intake Form 

Full Name

Mailing Address


Email Address

Telephone - Home

Telephone - Cell

Telephone - Work

Date of Birth

                                                            Male   or   Female

Referred by

List any injuries in past 5 years.

List any surgeries in past 5 years.

Check all medical conditions that apply.

___ Pregnancy             ____ Diseases             ____ Infections

___ Heart Condition      ____ Blood pressure

___ Breathing               ____ Blood clots         ____ Arthritis

____ Skin disorders      ____ Diabetes             ____ Cancer

___ Other (Please explain)


List any medications you are currently taking.

List any allergies or sensitivities.

Check the appropriate areas of concern.

___ Head              ___ Upper Back           ___ Knees

___ Legs               ___ Neck/Shoulders    ___ Lower Back

___ Feet/Ankles    ___ Other (Please explain)


Date & Time of First Service

Client's Signature


Massage Therapy Consent Form

By signing this consent form, I understand that Karen Robinson, LMT, CNMT  DOES NOT diagnose illness, disease or any other medical disorder. As such, Karen Robinson, LMT, CNMT  DOES NOT provide medical treatment or pharmaceuticals. I understand that any services provided are not a substitution for medical treatment and that I should see a physician for any physical ailment that I might have. Because massage therapists must be aware of any existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep Karen Robinson, LMT, CNMT  updated on my physical health. Therefore, I assume all risk for my health and hold harmless Karen Robinson, LMT, CNMT and any associated business entities, practitioners, or any persons involved in services performed.

I also understand that any illicit or sexually suggestive remarks or advances made by me to Karen Robinson, LMT, CNMT at any point will result in immediate termination of the session and or removal from the premises. In this case I will be held liable for payment “In full”.

I acknowledge Karen Robinson, LMT, CNMT maintains a 24 Hours Cancellation Policy. If I choose to cancel services in less than 24 hours, I am responsible for half (50%) the amount of the service fees.

I understand that questions about service procedures and recommendations are encouraged and welcomed.

Client's Signature


Print Name




Therapist’s Signature



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