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intakE FORM

Health History

The information provided in these forms is confidential and may only be shared with your written consent. 
Please select:
Have you received therapetic massage before?
Please check any painful or tense areas of the body that you are aware of:
Are you currently experiencing any of the following? Please mark all that apply:
Please select any of the following health issue that you have experienced.

Statement of Informed Consent

I understand that my consent is essential in receiving therapeutic touch and that I have complete agency in setting the boundaries for my body in these bodywork sessions. If I experience any pain or discomfort during a session, I will inform the therapist so that pressure and/or strokes may be adjusted to my level of comfort. I understand that massage therapy is not a substitute for medical examination, nor does the massage practitioner diagnose illness, disease, or any physical or mental condition. I understand that nothing that is said in the course
of our sessions should be construed as such. Furthermore, it is recommended that I see a primary health care provider for that purpose. I have provided all of my known medical information and will inform the therapist of any new information I become aware of while in
their care. I understand that there will be no liability on the therapist’s part should I fail to doso. I hereby give consent to receive therapeutic massage for the purpose of reducing stress, relieving muscular tension, spasm or pain, increasing circulation and energy flow, and facilitating healing from injury or trauma.

I agree to inform my therapist should I develop any COVID symptoms prior to our session together or should I discover that I have been in close contact with anyone who has tested positive for COVID-19 within 10 days of our session.

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