Massage Therapy Intake Form

Please fill out the following form after scheduling your first bodywork appointment.

Have you ever received Massage Therapy?
Are you suffering from a medical condition, illness, or injury?
Check any areas of the body you are NOT comfortable receiving bodywork:
  • I understand that the massage treatment(s) that I receive is/are provided for the purpose of relaxation, relief of stress, muscular tension, pain, and to aid the body with its natural healing process. A massage therapist works soft tissue and may integrate gentle range of motion exercises to the joints but will not administer spinal manipulations.

  • If I experience any pain or discomfort during the treatment I will immediately inform the therapist so that he can adjust his techniques and pressure to within my level of comfort. I am also informed that I have the right to stop massage treatment at any time.

  • I further understand that massage is not a substitute for medical examinations or diagnosis and so I should seek a physician or other health professional should I need aid with mental or physical ailments.

  • I am aware that on rare occasion massage therapy may cause delayed onset muscle soreness. If it should happen it should go away within 24-48 hours.

  • Because Massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

  • I understand that my bodywork therapist, Ceth, is not an RMT in Canada, and therefore sessions are not covered through any form of benefits.

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