If you have already scheduled an appointment, please take the time to download and complete the Client Intake and Authorization form below. You may turn this form in at the time of your scheduled session to expedite the intake process. (You may copy and paste this document if not downloadable)
Client Intake Form Revised 7/01/2009
Name ____________________________________________
Date _____/_____/_____
Mailing Address ________________________________________________________________________
City ____________________ State _______ Zip _______
Day Phone ( ) _________________
Eve Phone ( ) _________________
Occupation_________________________________________
Emergency Contact Name & Phone _______________________________________
E-mail _______________________________
Were you referred? If so, by who? __________
Please circle either YES or NO.
Have you ever received a professional massage? YES NO
Are you pregnant? If so, what trimester? _______ YES NO
Do you exercise frequently? YES NO
Are you currently under the care of a health care practitioner? YES NO
Are you currently taking any medications? YES NO
If yes, please list all medications ____________________________________________________
Have you recently been injured or sick? YES NO
If yes, please explain _____________________________________________________________
Have you ever had surgery? YES NO
If yes, please give the date of surgery and explain __________ ____________________________
Please circle any of the following that you now have or have had.
Bone or joint disease Tendonitis
Arthritis/Gout Jaw Pain (TMJ)
Lupus Asthma
Emphysema Sinus Infection(s)
Rashes Athletes foot
Herpes HIV/AIDS
Heart Condition High/Low Blood Pressure
Lymphedema Migraines
Ulcers Numbness/Tingling
Shingles Cancer
Sciatica Varicose Veins
Authorization and Release Form Revised 7/01/2009
I, ____________________, have completed, to the best of my knowledge, a client intake form and have informed my therapist of all known current health/medical conditions. I understand that a massage therapist cannot diagnose illness, disease, or any other medical, physical, or emotional disorder, nor perform any spinal manipulations. I understand that massage is not, or in any way, to take the place of medical care if so deemed necessary by a physician. I understand that massage is therapeutic and is in no way sexual. I understand that my therapist can terminate a session for any reason, if so deemed necessary, and that I am still to be financially responsible for my appointment. I understand that if I am late for my appointment, that I am still financially responsible for the full amount of my appointment and that my tardiness will deduct from the scheduled treatment time. I agree to give a 24 hour cancellation notice or else I would still be financially responsible for my appointment. I understand that a therapeutic massage session should not exceed, under any circumstances, 200 dollars and that the average rate of a massage is 60 to 100 dollars per hour.
I, ____________________, release Jeremy L. Hooper from any physical or medical condition that may arise post a treatment session. I also release the therapist from any damages/losses to my home that could occur in a private, in-home session.
Printed Name: ___________________________
Signature: ______________________________
Date: ______/______/________
