Intake Form

Massage therapy and Energy work is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I may have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis, I must provide a physician’s written consent prior to services. I affirm that I have notified the therapist of all known medical conditions and injuries, furthermore, I agree to inform the therapist of any changes in my health and medical condition and there shall be no liability on the therapist's part should I forget to do so.

The client will be fully clothed during the session. The licensee shall not engage in breast massage of female clients unless the client gives written consent before each session involving breast massage. The licensee must immediately end the massage session if a client initiates any verbal or physical contact that is sexual in nature. If the client is uncomfortable for any reason, the client may ask the licensee to end the massage, and the licensee will end the session. The licensee also has a right to end the session if uncomfortable for any reason.

By signing this form, I waive and release my therapist from any liability, past, present, and future, relating to massage therapy, body work, and energy work.