Massage Intake Form - Providence Apothecary (Page 2 of 2) in pdf

Massage I ntake F orm – P age 2 -‐ C ONFIDENTIAL I NFORMATION

Do y ou h ave a ny o f t he f ollowing t oday:

_____skin r ash

_____cold/flu

_____open c uts

_____severe p ain

_____anything c ontagious

_____injuries/bruises

Do y ou h ave a ny a llergies t o:

_____medications _____foods ( nuts, e tc.) _ ____environmental a llergens ( dust, p ollen, f ragrances)

_____reactions t o s kin c are p roducts

If a ny o f t he a bove a re c hecked, p lease g ive d etails: _ ___________________________________________________

_______________________________________________________________________________________________________________

Are y ou w earing: _ ____contact l enses _____hearing a id _ ____hairpiece

Please i ndicate w ith a n ( X), i f a ny, t he a reas i n w hich y ou a re f eeling d iscomfort:

What a re y our g oals/expectations f or t his t herapy s ession? _ _________________________________________

______________________________________________________________________________________________________________

The f ollowing s ometimes o ccurs d uring m assage. T hey a re n ormal r esponses t o r elaxation. T rust

your b ody t o e xpress w hat i t n eeds t o: Ÿ need t o m ove o r c hange p osition

Ÿsighing, y awning,

change i n b reathing

Ÿstomach g urgling

Ÿemotional f eelings a nd/or e xpression

Ÿmovement o f i ntestinal g as

Ÿenergy s hifts

Ÿfalling a sleep

Ÿmemories

Please r ead t he f ollowing i nformation a nd s ign b elow:

1. I u nderstand t hat a lthough m assage t herapy c an b e v ery t herapeutic, r elaxing a nd

reduce m uscular t ension, i t i s n ot a s ubstitute f or m edical e xamination, d iagnosis

and t reatment.

2. T his i s a t herapeutic m assage a nd a ny s exual r emarks o r a dvances w ill t erminate t he

session a nd I w ill b e l iable f or p ayment o f t he s cheduled t reatment.

3. B eing t hat m assage s hould n ot b e d one u nder c ertain m edical c onditions, I a ffirm t hat

I h ave a nswered a ll q uestions p ertaining t o m edical c onditions t ruthfully.

4. I a m a ware t hat a ppointment c ancellations n eed t o b e m ade p rior t o 2 4 h ours b efore t he

appointment s tart t ime. F ailure t o c ancel w ithin t he 2 4 h our p eriod c an r esult i n

late-‐cancellation f ees.

Signature: _ ____________________________________________

Date _ ____/_____/__________

Massage Intake Form - Providence Apothecary Page 2