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. Massage intake form confidential information welcome. I understand that i am receiving massage therapy at my own risk. Intake forms serve an important purpose, but are often disliked by both clients and massage therapists alike. If no photo id is available, we reserve the right to refuse service. Massage and bodywork intake form client information name city state zip date day phone eve phone. If at any time you have questions regarding your session. The therapist shall not engage in any type of breast massage of female. I understand that massage green spa is a tranquil and professional environment and that any inappropriate behavior may result in temination of my services and full payment is expected. Massage green the type of massage therapy service or techniques that i ancipate using during the massage therapy session is. By signing this form, i agree to the above terms and release massage green spa and its employees from any liability. By saving this client intake information in one easytoaccess massage intake form, licensed massage therapists can understand patients needs better and improve the long. Carolina birth and wellness massage intake form doulas. How to get clients to complete massage intake forms before.
Massage therapy client intake form template jotform. Client intake form therapeutic massage confidential. This client intake form app is intended to make it easier for professional massage therapists to collect and save important information about their massage therapy clients. Burke rehabilitation hospital l massage therapy adult fitness center 785 mamaroneck ave. Payment for massage is due at the time the service is received, unless other specific arrangements are made prior to the session beginning. A good way to create an appropriate intake form is using a massage intake form template. Information exchanged during any massage session is educational in nature and is intended to help you become more familiar and conscious of your own health status and is to be used at your own discretion. Generally, therapists require patients to fill out the massage intake form before their appointment. Clients hate wasting time filling out paperwork when theyd rather be on your. In the event that i become injured either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy i hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability. Also known as client intake form, a massage intake form is a way by which therapists record patient contact information, specify policies, and get an idea of the patients issues, medications, and contraindications. Information exchanged during any massage session is educational. This will avoid the overhead, expenses and risks related to paperbased.
I am aware that the massage therapist does not diagnose illness or disease, does not prescribe. Massage therapy intake contains different questions about personal information, contact information, history of pathology and the clients symptoms. Please practice handwashing and social distancing, and check out. With the increasing use of electronic patient intake forms, it makes sense to include the. With the increasing use of electronic patient intake forms, it makes sense to include the hipaa forms as part of the intake package you send to your patients. Please practice handwashing and social distancing, and check out our resources for adapting to these times. If you have a specific medical condition or specific symptoms, massagebodywork may be contraindicated. You can sign up for massage therapy with massage intake form template and you can create a hipaa compliant. And yet an intake form is important and shouldnt be ignored. Feb 6, 2017 explore ctruax1s board massage intake forms, followed by 266 people on. Minor release form all persons under the age of 18 are required to have a parent or guardian fill out this form.
By signing below, you agree that you are the parent or legal guardian of the minor receiving treatments at our facility. We support a wide range of question formats, including body diagrams. Paper intake forms make for a bad customer experience. Thankfully, there is a better way for both client and. Client intake form therapeutic massageconfidential. I acknowledge that massage therapy is not a substitute for medical diagnosis and treatment.
Massage therapist lmt client intake application form mobile. If at any time you have questions regarding your session, please let us know. I would like to make your appointment as pleasant and comfortable as possible. You should be able to answer the following so the therapists will know if the type of massage that you want is appropriate for you and so that they can also make suggestions. If at any time you have questions regarding your session, please let me know. Because massage should not be performed under certain medical conditions, i affirm that i have stated all my known medical conditions and answered all questions on the client intake form honestly. The form has four sections namely the client information section, session information section, previous history section, and an acknowledgment section. Name phone day phone eve address citystatezip email date of birth occupation emergency contact phone the following information will be used to help plan safe and effective massage sessions. Are you currently under the care of a health care practitioner. Because massage and bodywork therapy may be contraindicated due to certain medical conditions, i affirm that i have informed the therapist of all known medical. In addition, first time cash massageacupuncture or outofstate patients are required to.
You should be able to answer the following so the therapists will know if the. We would like to make your appointment as pleasant and comfortable as possible. Massage therapy intake form templates creating your form templates is easy with our form editor, but you can also just send us your existing forms and we will set everything up for you. A new client shows up right at 10am for their 10am appointment, forgetting that theyll need 5 to 10 minutes to complete their intake form. I have completed this form to the best of my ability and knowledge. Also known as client intake form, a massage intake form is a way by which therapists record patient contact information, specify policies, and get an idea of the. A client form or a massage intake form is basically used to know your background with regards to therapeutic massage.
Client intake form therapeutic massage personal information. A referral from your primary care provider may be required prior to service being provided. Client intake form therapeutic massage webster muscular. In addition, first time cash massage acupuncture or outofstate patients are required to provide a photo id and completed intake form. I understand the massage services are designed to be a health aid and are in no way to take the place of a doctors care when it is indicated. Massage client intake form general and medical information. I have completed this form to the best of my knowledge and will inform the massage. I give my consent to eszter gozon, lmt to provide treatment. The therapist shall not engage in any type of breast massage of female clients without the wrien consent of the client. At elements we do not perform any massage without proper draping. Now youre either behind schedule or the client is upset their 60 minutes of treatment time is down to 50 minutes. Also, client intake form massage is used by chiropractors. Name phone day phone eve address citystatezip email date of birth occupation emergency contact phone the following.
Massage and bodywork intake form client information name city state zip date day phone eve phone occupation date of birth emergency contact name and phone if yes, specify purpose. Massage therapy intake form all intake information is confidential. Swedish, deep tissue, trigger point, sports, andor esalen style massage, for relaxation and relief of muscle pain andor lymphatic drainage therapy for. Massage therapy client intake please mark the areas to identify your symptoms today. The following information will be used to help plan safe and effective massage sessions. Please include accurate information to the best of your ability in order to ensure a safe and rewarding treatment. Indulge spa informed consent massage, manicures, and more. Free massage intake forms massage therapy intake form pdf. By signing this form and going through our intake process, you affirm that you have answered all questions honestly and that there is no liability on the therapist in the case you do not disclose any. A statement of the type of massage techniques to be used. By signing below, you agree that you are the parent or legal guardian of the minor receiving.
Draping means that your body will be modestly covered by a sheet during the massage. Massage space galina fedtchenko, lmp ma00023411 massagespace. Clients hate wasting time filling out paperwork when theyd rather be on your table, and you have to remember important intake information for follow up sessions as well as keeping track of all that paper. Feb 20, 2014 1 page massage intake form client salon forms welcome to salon dg a full service hair, nails. I have not experienced any of the complications listed on the attached sheet. You understand that you are required to remain at the facility for the entirety of the minors treatments.
This is the common type of massage intake form that can be provided to all massage clients. For all first time clients to the clinic payment for massage or acupuncture treatment is required beforehand. Underline past conditions check here if explanation below. Please answer the questions to the best of your knowledge. The massage therapist will not perform breast massage on female clients without the written consent of the client elements does not perform breast massage. Cpmassagemassageclientintakeformnewo8 82508 501 gateway drive, suite 104 clayton nc 27520. I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health. The following information will be used to help plan safe and effective massagesessions. Oncology massage intake form must accompany a complete. Massage therapist lmt client intake application form. By signing this form and going through our intake process, you affirm that you have answered all questions honestly and that there is no liability on the therapist in the case you do not disclose any conditions or update him or her with regards to changes in your medical condition that might impact your reason to receive massage. When i was still a practicing massage therapist, i would briefly talk through the completed intake form with a new client and would then file the paper form. A statement that if the client is uncomfortable for any reason, the client. A new client shows up right at 10am for their 10am appointment, forgetting that theyll need 5 to 10 minutes to complete.