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Client Intake Form

Birthday
How would you rate your general health?

Health History

Cardiovascular
Head & Neck
Musculoskeletal
Neurological
Respiratory
Reproductive
Skin
Miscellaneous

Waiver

Please read and sign:


• I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.

• If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible

for any pain or discomfort I experience during or after the session.

• I understand that today's services are not a substitute for medical care and that my therapist is not

qualified to diagnose, prescribe, or treat physical/mental illness.

• I affirm that I have notified my therapist of all known medical conditions and injuries.

• I agree to inform the therapist of any changes in my health and medical condition and that there shall be no liability on the therapist's part should I forget to do so.

• I understand that massage is entirely therapeutic and non-sexual in nature.

• By signing this release, I waive and release my therapist from any liability, past, present, and

future, relating to massage therapy and bodywork.

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