Massage Intake Form

Personal Information

Name(Required)

First Middle Last

Phone (Home)

Phone (Cell)(Required)

Phone (Work)

Emergency Contact Information

Emergency Contact(Required)

First and last name

Relationship(Required)

Phone (Home)

Phone (Cell)(Required)

Phone (Work)

Medical Information

Are you currently taking any medications?(Required)

Yes

If yes, please list all medications and frequency of usage

Are you currently pregnant?(Required)

Yes

If yes, how far along?

Any risk factors?

Do you suffer from chronic pain?(Required)

Yes

If yes, please explain why and what makes it feel better and worse

Have you had any orthopedic injuries?(Required)

Yes

If yes, please list

Do you have any skin conditions (bruises, rashes, acne)?(Required)

Yes

If yes, please list

Please indicate any of the following that apply to you

List any other conditions you have here

Massage Information

Have you had a professional massage before?(Required)

Yes

What type of pressure do you prefer?(Required)

Light

Medium

Deep

Not Sure

Do you have any allergies or sensitivities?(Required)

Yes

If yes, please explain

What are your goals for this treatment session?

Please list any areas of discomfort(Required)

Please take a moment to read and initial the following statements and sign below where indicated.

Massage Therapy for wellness. I understand that the services I receive is provided for the purpose of wellness and body maintenance and services may include modalities that are designed to enhance physical fitness, mental attitudes, and alertness.(Required)

Client Health Warranty I am not aware of any disability, impairment, or ailment preventing me from receiving massage therapy. I affirm that I have stated all my known medical conditions and injuries and answered all questions honestly. I agree to keep the massage therapists updated as to any changes in my health profile, and understand that there shall not be liability on the massage therapist’s part should I forget to do so.(Required)

Massage Therapist role in client wellness. I understand that massage therapists are not qualified to diagnose or prescribe for disease conditions and that nothing said, done, performed, typed, printed or produced is intended or meant to diagnose, prescribe, treat a disease or takes the place of a licensed physician, chiropractor, registered dietitian or other qualified health professional. I understand that body maintenance assessments and suggestions are intended only for the support of optimal health and do not involve diagnosing, prognosticating, or prescribing any remedies for the treatment of disease conditions.(Required)

Client responsibility for their wellness. I understand that I accept total responsibility for my own health care and maintenance and that I should seek treatment from a physician, chiropractor, registered dietitian or other qualified medical specialist for any medical conditions that I am aware of.(Required)

Clients right to manage their massage therapy session. If I experience any pain or discomfort, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort.(Required)

Therapist’s right to refuse service. I understand that the therapist may choose to end any massage therapy session if they believe massage therapy could be detrimental to the client, the client is under the influence of drugs or alcohol, or the client exhibits any inappropriate behavior towards the therapist.(Required)

Professional Draping. For all services that require the client to undress; professional draping will be used during the session.(Required)

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19 The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to The virus that causes COVID-19 is spreading from person-to-person. People are thought to be most contagious when they are symptomatic (the sickest). (1). 1As a result, federal, state, and local governments and federal and state health agencies recommend social distancing, wearing a mask, and have, in many locations, prohibited the congregation of groups of people. Ascend Fitness & Spa has put in place preventative measures to reduce the spread of COVID-19; however, Ascend Fitness & Spa cannot guarantee that you or your child(ren)will not become infected with COVID-19. Further, visiting Ascend Fitness & Spa; receiving Ascend Fitness & Spa services, including but not limited to massage therapy, personal training; or utilizing the Ascend Fitness areas and equipment could increase your risk and your child(ren)’s risk of contracting COVID-19. By agreeing, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I or my child(ren) may be exposed too.(Required)

I hereby affirm that I have read, fully understand, and therefore consent to participating with Ascend Fitness & Spa in programs and services within the framework stated above.(Required)

Print Name(Required)

Date(Required)

Parent/Guardian Signature (if client is under 18 years of age):

Date

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Please complete to enhance your massage experience