Client Intake Form
All information is held strictest confidence. At no given point is information disclosed or shared without your written consent.
All essential fields are marked with a red asterisk.
You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Please put N/A for any question marked with an asterisk which doesn't relate to you.
History of Pathology (i.e. any injuries, surgery, current aches, pains or tension)
Please check any symptoms that apply to you and indicate right or left when applicable:
Please check any of the following conditions that apply to you:
Client services and chart information are confidential. Written authorization is required from you to release any information.
• Please turn off your mobile phone for optimal relaxation
• Your scheduled session is set aside for you. We do not double book appointments
• Please reschedule your session if you are more than 15 minutes late
• 24 hour cancellation notice is required to avoid being charged for your session
• You will be draped and at no time will genitalia or breast tissue be exposed
• You will have a prior consultation with your therapist to discuss your session
• Should the session require, after your therapist has left the room, you may disrobe to your comfort level
• I understand that my therapeutic massage therapist or I may end the session at any time for any reason
• Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law
I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.
I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.
It is my choice to receive therapeutic massage as a form of therapy.
I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.
I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.
I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.
I understand that my failure to do so may post a threat to my health and/physical well being and I hold Revitalizar Holistic Massage Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.
By my electronic signature below, I agree to the massage policy and client agreement above.