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MAJESTIC MASSAGE CLIENT INTAKE FORM
Today's Date
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MM
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DD
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Name
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First
Last
Address
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Street Address
City
State / Province / Region
Postal / Zip Code
Date of Birth
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Under the age of 18
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Yes
No
Primary Reason for Visit
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Previous Experience with Massage
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Current Medications
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How Did You Hear About Us?
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Please Check ALL Conditions that Apply Now or in the Past:
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Diabetes
Arthritis
Blood Clot
Broken Bone
Bruise Easily
Cancer
AIDS
Hepatitis
Stroke
Surgery
Headaches
Insomnia
Allergies
Seizures
Scoliosis
Numbness/Tingling
High Blood Pressure
Sinus Problems
Rashes
Athlete's Foot
Pregnancy
Heart/Lung Conditions
Muscle Strain/Sprain
Depression/Panic Disorder
None
Hold down Ctrl key to select multiple answers.
Other Conditions We Should Be Aware Of:
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Terms & Conditions
I understand that the massage/bodywork given here is for the purpose of stress reduction, relief from muscular tension or for increasing circulation and energy flow. I understand that Massage Therapists do not diagnose illness or disease, nor do they prescribe any medical treatments. I acknowledge that massage is not a substitute for medical examination or diagnosis and it is recommended that I see a health care provider. Because massage/bodywork should not be done under certain medical conditions, I affirm that I have stated all medical conditions and answered all questions honestly. I will keep the Massage Therapist updated as to any changes in my medical profile and understand that there shall be no liability on the Massage Therapist part should I forget to do so.
I also understand that any sexually suggestive remarks or advances made by me, the client, will result in immediate termination of the session and I will be liable for payment in full for the entire session.
No Call/No Show Policy
In an effort to provide effective and efficient treatment to all of our clients, it is the policy of this wellness spa that all appointment cancelations are made at least 24 Hours prior to your scheduled appointment time.
If an appointment is not cancelled or client fails to show up for appointment, Majestic Massage
reserves the right to charge client full price of services.
As this is fee is not billed to any insurance company, clients accepts full responsibility to pay
this fee.
Emergencies will be treated individually.
I agree with the above terms and conditions
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Yes
No
Client Signature
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Clear
Date Client Signed
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Massage Therapist Signature
Clear
Date Massage Therapist Signed
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DD
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