Massage + Bodywork Intake Form

Personal Information
Medical Information
Are you currently under the care of a health care practitioner?
Are you currently pregnant? If yes, please refer to Pregnancy Massage Intake Form.
Please indicate any of the following that apply to you:
Have you had a professional massage before?
Do you have difficulty lying on your front, back or side?
Do you have allergies to oils, lotions, ointments or nuts?
Are there any areas (feet, abdomen, etc.) you DON'T want massaged?
What type of massage are you seeking?
Are there any specific areas you would like the massage therapist to concentrate on during your session.

I, ______________________________ , understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension.  If I experience pain or discomfort during this massage session, I will immediately inform the Therapist so that the pressure may be adjusted to my level of comfort.  I understand that massage is not a substitute for medical diagnosis and treatment and that I am responsible for consulting a Health Care Professional for any physical ailments that I am aware of.  I understand that Massage Therapists are not qualified to perform spinal manipulations or skeletal adjustments. I affirm I have stated all my known medical conditions and answered the questions honestly.  I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.  I also understand that the License Massage Therapist reserves the right to refuse to perform massage on anyone whom he/she deems to have a condition for which massage is contraindicated.  


I understand that response to treatment varies on an individual basis and that specific results are not guaranteed.  Therefore, in consideration for any treatment received, I agree to indemnify, hold harmless and release from any and all liability White Lotus Day Spa as well as any owners, officers, directors, assigns, insurers, independent contractors or employees of the above company for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.  I understand that White Lotus Day Spa staff members have the right to refuse service if any client’s conduct is disruptive or inappropriate.   I understand that if I cancel an appointment less than 24 hours in advance or am late for an appointment I may be charged for the full scheduled session.


Signed ______________________________________________    

I agree that inputting my full name above acts as an electronic signature. The information above is accurate.

Thanks for submitting!