Massage Therapy Client Intake Form

Client Intake Form

Please tell us a bit about yourself

All information is confidential, at no given point is information disclosed or shared without client’s written consent
Name: *

First Name Last Name
Birth Date: *

Month Day Year
Phone: *

Area Code Phone Number
This is my: *
E-mail: *
Occupation: *
How did you hear about Aequilibria Massage? *
If referred by someone who?
Have you had a massage before? *

Yes No First Massage
If Yes, how long ago?
Are you pregnant? If so how far along?
Please describe any issues you've currently been experiencing with your body and how you'd like your therapist to help you with those areas. *
Any particular area(s) to focus on? *
Any particular area(s) to avoid?
What kind of pressure were you looking for today?
Are you currently under the care of a physician, chiropractor, psychologist, or physical therapist for an ongoing condition or problem? *
Have you had any major surgical procedure? *
If yes, briefly explain:
Is your condition related to an accident or injury? *
If Yes, describe accident and approximate date
If yes, please list medication(s)
Please check all that apply: *

Not currently ill Cold Flu Fever Infection Contagious Disease
Certain medical conditions or symptoms may be aggravated or get worse by receiving a massage. A referral from your primary care provider may be requested before your session. You are encouraged to check with your doctor to be sure massage therapy is appropriate for you. This includes musculoskeletal,circulatory, respiratory and skin conditions. If your condition is not below please mark other and advise.
Are you currently experiencing symptoms of any of the following conditions? If you currently are ill your session MUST be rescheduled for 48 hours after symptoms subsides. To protect the health of our clients and team members we reserve the right to refuse treatment to anyone that is ill.
Please check all that apply: *

No health Issues Diabetes Cancer Stroke Surgery Joint Ache Pregnant Seizures Whiplash Headaches Migraines Contact Lenses Strain/Sprain Anxiety/Panic Attacks Skin Conditions Heart Condition Broken Bone Dislocated Bone Blood Pressure Slipped Disk Herniated Disk Auto-Immune Disease Viral Disease Arthritis Tree Nut Allergy Other Allergies Varicose veins Blood clots Asthma Sinus Issues Open Wound/Sore Fungal infections Warts Athlete's Foot Tourette Syndrome Breast Augmentation
Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off your cell phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please arrive 10 minutes before your schedule time of appointment

       • 12 hour cancellation notice is required to avoid being charged for your session

       • Per Georgia law you will be draped and at no time will genitalia or breast tissue be exposed

       • You will have a brief consultation with your therapist to discuss your session

       • After your therapist has left the room, you may disrobe to your comfort level

       • I understand that my 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

Client Agreement:

I understand that Massage Therapists do not diagnose, prescribe or replace the treatment or advice of a physician,

nor do they perform any spinal manipulations. I acknowledge that the massage therapy received at Aequilibria Massage studio

is for therapeutic reasons such as reducing stress and muscular tension only and is not a substitute for medical

treatment. I understand that it is recommended for me to see a physician for any physical, mental or medicinal need

and I am encouraged to inquire about massage therapy being safe for any of my conditions. I also understand that

at any time I feel pain or discomfort during the session, I will immediately inform my Massage Therapist so they can

adjust the pressure to my comfort. I have informed my Massage Therapist of all known medical conditions and

understand it is my responsibility to keep my Massage Therapist updated on my physical health.

I understand that my failure to do so may pose a threat to my health and/or physical well being and I hold

harmless Avani Massage and my 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.
Signature: *

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse. Clear
Date: *

Month Day Year Hour Minutes AM/PM Option
Should be Empty: