Massage Therapy Intake & Consent Form

All clients must fill out this form prior to their first massage session or whenever any medical conditions change.

MASSAGE THERAPY INTAKE & CONSENT FORM

First name

Last name

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency Contact Name

Emergency Contact Phone Number

What do you hope to achieve through massage therapy? (relaxation, stress relief, muscle pain, etc)

Pressure Preference

Light

Medium

Firm

Deep

Areas of pain / tension:

List details regarding any Allergies, Injuries, Surgeries, or other pertinent information:

Check each box below to acknowledge the specific health risks associated with each available add-on therapy.

Hot Stone Therapy - Uses heated stones to relax muscles. Not safe if: You have nerve damage, heat sensitivity, or take blood thinners.

Cupping Therapy - Uses suction cups to increase blood flow. Note: May cause temporary skin discoloration or bruising

Aromatherapy - Uses concentrated plant essential oils. Not safe if: You have asthma, severe allergies, or chemical sensitivities.

Paraffin Wax - Heated wax treatment for hands/feet. Not safe if: You have open wounds, poor circulation, or numbness.

Policies & Informed Consent

Scope of Practice: I understand that massage therapy is intended for relaxation, stress reduction, relief from muscular tension, and

improvement of circulation. I explicitly acknowledge that massage therapists do not diagnose medical illnesses, prescribe medications, or

perform spinal manipulations.

• Client Responsibility: I affirm that I have stated all known medical conditions and answered all questions honestly. I agree to keep the

therapist updated on any changes in my health profile during future sessions. I understand that failure to disclose health information could

result in injury.

• Risks & Comfort: I recognize that while massage therapy is generally safe, there are minor risks including temporary muscle soreness or

bruising. I understand that I have the right to request changes in pressure, technique, or to terminate the session immediately at any point if I

experience discomfort.

• Professional Boundaries: I understand that this massage session is completely therapeutic and non-sexual in nature. Any illicit,

suggestive, or inappropriate remarks or actions will result in the immediate termination of the session, and the full session fee will remain due.

• Cancellation & Deposit Policy: I understand that any appointment cancellations or modifications must be made at least 24 hours before the scheduled start time. If I fail to provide 24 hours' notice, my security deposit will be strictly non-refundable.

Signature

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