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Massage Therapy
Client History/Intake Form
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Full Name |
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Mailing Address |
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City/State/Zip |
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Email Address |
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Telephone - Home |
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Telephone - Cell |
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Telephone - Work |
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Date of Birth |
Male or Female |
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Referred by |
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List any injuries in past 5 years. |
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List any surgeries in past 5 years. |
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Check all medical conditions that apply. |
___ Pregnancy ____ Diseases
____ Infections
___ Heart Condition ____ Blood pressure
___ Breathing ____
Blood clots ____ Arthritis
____ Skin disorders ____ Diabetes
____ Cancer
___ Other (Please explain)
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List any medications you are currently taking. |
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List any allergies or sensitivities. |
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Check the appropriate areas of concern. |
___ Head ___ Upper Back
___ Knees
___ Legs ___ Neck/Shoulders
___ Lower Back
___ Feet/Ankles ___ Other (Please explain)
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Date & Time of First Service |
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Client's Signature |
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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.
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Client's Signature |
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Print Name |
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Date |
________________________________________ |
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Therapist’s Signature |
________________________________________ |
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