Confidential Intake & Consent Form

Intake Form 2025

Emergency Contact


The following information will be used to help plan safe and effective massage therapy sessions. Please answer the questions to the best of your comfort and knowledge.


Medical History


Please check one of the following.


Please read ALL of the below and click "Agree & Submit Intake Form" at the bottom.


Sick Policy

Massage/bodywork is not appropriate care for infectious or contagious illness. Please cancel your appointment as soon as you are aware of an infectious or contagious condition. If it is within the 24-hour notice period, the cancellation fee may be waived.

Amid the ongoing uncertainty of COVID-19, we have modified our cancellation policy to offer greater flexibility to all our clients in the case of illness. If you have respiratory or flu-like symptoms, please stay home, rather than feel obligated to keep your appointment. Please let us know as soon as possible. We will not charge you for a late cancellation, if you are sick with a cold or flu.

Missed Appointment and Cancellation Policy

Please give at least 48 hours notice with cancellations. Less than 24-hours will incur full cost of your appointment. Thank you for your accountability and understanding.

Arriving Late

All massage sessions have a specific time schedule and an early arrival allows for a relaxed and unhurried experience. If late arrival is inevitable, your service may be shortened in order to keep on schedule and you will be expected to pay the original appointment rate.

I understand that...

I understand that Massage Therapists are not medical doctors and are not substitutes for medical treatment.  We also do not diagnose, prescribe medications, or perform spinal manipulations.

I understand that it is my responsibility to fully inform the Massage Therapist with all medical conditions, symptoms, medications, etc. I am also responsible to answer all questions about my health and physical condition honestly and in full detail. I understand that it is solely my responsibility to keep the Therapist updated on any changes in my health and physical conditions. I also understand that it is my responsibility to communicate with my Massage Therapist if I have any questions or concerns regarding my session.

I do not have any symptoms or injuries or conditions that would prevent me from receiving Massage Therapy, nor have I been told by a health care provider that I should not receive Massage Therapy. The Therapist has the right to decline, discontinue or restrict services at any time based on information that may put my own health or the Therapist’s health at risk.

I understand that massage and bodywork are therapeutic, clinical, and non-sexual. Only area(s) currently being worked on will be professionally and adequately undraped. In certain cases, undraped breast work may be performed to best move lymphatic fluid away from blocked or congested areas. I understand that having undraped breast work is performed clinically and professionally and in no way conducted in an inappropriate or sexual manner.


I understand that my Massage Therapist reserves the right to refuse treatment or end a session immediately, in the case of sexual innuendos or advances or other inappropriate behavior by the client. I also understand that I am responsible for full payment of the scheduled session.