Massage Therapy Intake Form - Beverly Hills Day Spa

PERSONAL INFORMATION

Name *

First

Last Name

Last

Date of Birth

Address

City

State/Province

Zip/Postal

Email *

Phone

May we add you to our e-mail list?

Yes

No, thank you

Emergency Contact

Phone

HEALTH INFORMATION

(Please select all that apply)

Primary Physician

Phone

May we contact, if necessary?

Yes

No

Regularly Exercise?

How many times a week?

Allergies

Allergies?

Please list allergies

Medications?

Please list medications

Recent Surgery

Recent Surgery?

What kind of surgery?

When?

Women Only

Pregnant (if yes, annotate trimester)Pregnant (if yes, annotate trimester)

Nursing

Birth Control

MESSAGE PREFERENCES

(Please select all that apply)

Length of Massage:

30 Minutes

60 Minutes

90 Minutes

DESIRED RESULTS

(Please select all that apply)

MASSAGE HISTORY

(Please select all that apply)

Have you ever had a professional massage before?

Yes

No

When

Where

Beverly Hills Day Spa

OtherOther

Was your body sore afterwards?

Yes

No

Where on your body were you sore?

CONSENT AGREEMENT

Consent Agreement

<em>If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to therapy being provided. I further understand that it is my responsibility to keep the therapist informed/updated of any medication or health changes. If I experience any pain or discomfort during this session, I will immediately inform the Licensed Massage Therapist (LMT) so that the pressure is adjusted to my comfort level. I also understand that massage/ bodywork should not be construed as a substitute treatment for any mental or physical aliment that I am aware. I understand that LMTs are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the sessions given should be construed as such. Because massage/body work should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered the questions honestly. I agree to keep the LMT updated as to any changes in my profile and understand that there shall be no liability on the LMT's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in. the immediate termination of 1he session and I will be liable for payment of the appointment. You will be professionally covered underneath a large sheet, which will cover body parts not being massaged. Florida Licensed Massage Therapists are governed by the Dept. of Health and are required by law to conduct themselves ethically and within the scope of wellness.</em>

CANCELLATION POLICY

Cancellation Policy

Print Client Name

Signature

Clear

Date

TREATMENT OF A MINOR

I hereby authorize a Licensed Massage Therapist to perform service of massage therapy for my child/dependent.

Print Guardian Name

Guardian Signature

Clear

Date