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CLIENT INTAKE FORM

(For the clients with an existing appointment)

Birthday
Day
Month
Year
Do you have any of the following conditions?
If you are pregnant, please select what applies
Are you currently receiving any of the following treatments?
A re you currently being treated for any medical condition?
No
If yes, please specify
Are you currently taking any medication?
No
If yes, please specify
Are you currently taking any supplements?
No
If yes, please specify
Do you have any allergies
No
If yes, please specify
Are you currently experiencing any pain or struggle?
How did you hear about us?
Facebook
Instagram
Friend/Family
Walked past
Car advertising
Google
Other
Do you allow me to make any photos/filming for marketing purposes?
YES
NO

Massage Therapy Terms & Contraindications


Please read the following carefully before your session.


General Understanding

  • I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular and emotional tension.

  • If I experience any pain or discomfort during the session, I will immediately inform the therapist so that pressure or technique may be adjusted to my comfort.

  • I understand that massage is not a substitute for medical examination, diagnosis, or treatment.

  • I acknowledge that Massage Therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and nothing said in the course of a session should be construed as such.

  • Massage should not be performed under certain medical conditions. I affirm that I have stated all known medical conditions and answered all questions honestly. I agree to update my therapist regarding any changes to my health profile before future sessions.

  • I understand that the Massage Therapist reserves the right to refuse treatment if they deem that massage may be contraindicated.

  • I acknowledge that the therapist is not responsible for adverse reactions that may occur if contraindications are not disclosed or if medical advice has not been sought where recommended.


Contraindications for Massage During Pregnancy

Massage may not be suitable if you are experiencing:

  • First trimester complications (e.g. unexplained bleeding, cramping)

  • High-risk pregnancy (placenta previa, pre-eclampsia, gestational hypertension)

  • Severe swelling or sudden onset of edema

  • History of recurrent miscarriage

  • Unexplained abdominal pain

  • Fever, flu, or active infection


Contraindications for Manual Lymphatic Drainage (MLD)

MLD may not be suitable if you have:

  • Active infection or fever

  • Acute inflammation (e.g. cellulitis, erysipelas)

  • Untreated heart conditions (heart failure, severe arrhythmia)

  • Untreated kidney disease or renal failure

  • Untreated blood clots (deep vein thrombosis, thrombophlebitis)

  • Active cancer unless written clearance is provided by your oncologist

  • Acute or unstable asthma

  • Recent major surgery without medical clearance


Contraindications for Scar Work

Scar massage may not be suitable if:

  • The incision/surgical site is less than ~6 weeks post-operation or you have not received medical clearance

  • The scar site is still open, unhealed, or has scabs/crusts

  • There is active infection or signs of infection (redness, swelling, heat, discharge)

  • There is significant swelling, edema, or inflammation not yet evaluated by a health professional

  • Pain is severe, or increases significantly during or after the session

  • You have a medical condition affecting healing (e.g. uncontrolled diabetes, immune suppression, poor circulation) without medical clearance

  • The scar is from a skin graft or has undergone radiation treatment unless cleared by your doctor

  • There is nearby internal hardware or joint replacement, unless cleared by a healthcare provider



Acknowledgement

By signing below, I confirm that I have read and understood these terms and contraindications. If I am unsure whether massage is appropriate for me, I will consult my healthcare provider before receiving treatment.

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