Bodywork Intake Form

Email

Phone Number

Referred by

Gender

Age

List Current Medications and the conditions they are treating:

List any major accidents or surgeries (including dates):

List any allergies or hypersensitivities:

What sports or activities do you participate in?

Text

Please check any of the following you are experiencing:

Any other known disease or illness:

I affirm that I have notified my therapist of all known medical conditions.

I agree to inform my therapist of any changes in my health or medical condition.

I hereby waive and release my therapist of any and all liability, past, present, and future relating to massage therapy and bodywork.

I understand that the services provided are not a substitute for medical care.

I understand there may be light bruising or soreness depending on the treatment used today.